AC132-S (Effective 4/12)
State
of
New York
EMPLOYEE REPORT OF TRAVEL EXPENSES
AND CLAIM FOR PAYMENT
Agency Name
Business Unit/Department Code
Employee ID
Official Station
Last Name
First Name
MI
Suffix
Address
City
State
Zip
Normal Work Hours
Business Purpose
Travel Destination
Travel Start Date and Time
Travel End Date and Time
Check if used:
Corp Card Advance Direct Bill
Travel Description
1. Indicate All Travel Expenses
If more space is required in any section, use the
associated detail form (number shown in parentheses below)
Totals 2. Summary Amount
Lodging
A. Total Travel Expenses
B. Subtract Amount Paid with
Travel Advance
Transportation (AC3259-S)
C. Subtract Amount Billed to
Corp Card (AC3256-S)
D. Other Direct Bill to Agency
(Specify)
Meals (AC3258-S)
Overnight Per Diem @ $ each =
Additional Breakfast @ $ each + Additional Dinner @ $ each =
Day Trip Breakfast @ $ each + Day Trip Dinner @ $ each =
E. Other Adjustments (Specify)
Mileage Claimed (AC160-S)
@ ¢ per mile =
Incidental Expenses – List (AC3259-S)
Total Travel Expenses – Enter in Section 2 Line A
Total Amount Claimed
Traveler’s Certification
I hereby certify that the above account and attached schedules are just, true and correct, that no part thereof has been paid, except as stated therein, and that the
balance therein stated is actually due and owing, and that the amounts claimed were necessary an incurred in the performance of my official duties.
Signature Title Date
Supervisor’s Certification (if required)
I, the claimant’s supervisor, certify that this account has been examined and to the best of my knowledge and belief, the amounts claimed therein were necessary
for the performance of the claimant’s authorized official duties.
Signature Title Date
FOR AGENCY USE ONLY
Entered by
Date
