Yes No
Yes No
Travel Location:
- - -
- - -
$
$
$
$
$
# of Days
$
$
$
$
Postage/Shipping: $
$
$
$
$
- - -
If yes, enter estimated round trip miles
(For Rental Cars ONLY)
Imprest
General Trip Data:
Fax Telephone No:
LOS ANGELES UNIFIED SCHOOL DISTRICT
REQUEST FOR TRAVEL AND ATTENDANCE AT CONFERENCE, CONVENTION OR MEETING
District Employee
District Parent
Semi-Monthly
Point of contact (SAA for Schools/Travel Site Specialist for non-School based Offices):
TRAVEL & CONFERENCE ATTENDANCE INFORMATION
Certificated
Classified
Job Class Code:
E-East
Form 10.12.1 (rev 04/16)
NE-Northeast
T-Card
self-paid
520002
520002
self-paid
District Paid
Local District Offices Legend:
C - Central
Airline:
self-paid
T-Card
self-paid
self-paid
Rental Agency
Functional Area
Agency Name
# of Days
# of Days
Business Purpose
Outside Agency ***
*** Substitute(s): If an outside organization is providing the funding for the substitute(s). Please indicate the expense budget line used for the substitute(s):
Grant
Conf. Fee:
PO/Shopping Cart
T-Card
Address:
Conference Title:
Region/State:
self-paid
# of Days
Name:
Employee Number:
Work Telephone No:
Name (First)
Personnel Number:*
School/Office Name:
T-Card
self-paid
Cost Center
District Paid
T-Card
Car Rental:
District Paid
Mileage:
# of Half Days
self-paid
(Signature)
Taxi/Shuttles:
Cost Center
Order
WBS Element
self-paid
Fund
self-paid
Business Purpose
Meals provided at conference?
T-Card
(Date)
Affidavit: I have read and understand the guidelines of Bulletin 5525.3 and declare under penalty of perjury that the foregoing is true and correct.
(Date)
** (If additional approval required) (Print Name and Title)
Approved by:
(Date)
(Signature)
** (If additional approval required) (Print Name and Title)
(Signature)
(Date)
Approved by:
Gasoline:
ESTIMATED EXPENSES:
(Signature)
Miscellaneous:
Substitute:
Approved:
% Distribution
TOTAL ESTIMATED EXPENSES: $
self-paid
T-Card
Hotel:
Approved by:
(Print Name and Title)
# of Full Days
Traveler:
Parking:
Conf. Rm:
Per Diem:
P-Card
Airfare:
Baggage:
Time
If yes, please attach map showing distance from school/work to event location.
Return
AM
Time
AM
Departure
% Distribution
Cost Center
GL
Zip:
# of Days
Hotel Name:
Comments:
Fund
Grant
Functional Area
Order/WBS Element
Email:
Telephone:
NW-Northwest
S-South
# of Rooms/Booths
Business Purpose
Encumber funds from Expense Budget Line: Funds must be available at the time of entry into SAP.
Please select TRIP TYPE from the Drop-Down Menu
Trip Activity:
Loc. Dist. Office:
Start Location:
End Location:
Will your personal vehicle be used to get to the destination?
Is mileage reimbursement being requested?
O-Non-School Based Office (i.e. Beaudry)
Trip Type:
Please select TRIP ACTIVITY from the Drop-Down Menu
0.00
0.00
0.00
0.00
O
Local (within 45 miles of work)
Conference-Classified
Trip #
Pers#
LOS ANGELES UNIFIED SCHOOL DISTRICT
TRAVEL EXPENSE CLAIM
Form 10.12.1 (REV) 04/16)
REIMBURSEMENT FOR INCURRED EXPENSES: Attach legible photocopies of receipts, cancelled checks, page(s) of the conference
brochure that show the date, place, conference fees (do not include other pages of the brochure), and other documentation for itemized expenses.
Please tape these receipts, stubs, cancelled checks, etc. to an 8-1/2 x 11” paper before photocopying/scanning. The original copies of the supporting
documents must be kept at the requester’s site and should be made available for future audits. This requirement for legible photocopies of supporting
documentation is needed to enable Accounts Payable to process travel expense claim documents through SAP Travel Management Module (TMM).
School-based travelers must submit the approved Form 10.12.2 with the approved Travel Expense Claim Form to Accounts Payable Section, Travel
Desk, Beaudry Building 27
th
floor. Accounts Payable will review, approve and settle the claim to Payroll for reimbursement in the next regular,
scheduled payroll run. Reimbursements will be sent to the traveler’s address on record via payroll with paycheck or direct deposit.
Non-school Based Office travelers must submit Travel Expense Claim Form with the supporting documents to the Site Travel Specialist to be
scanned and attached into TMM. Accounts Payable will review, approve and settle the claim to Payroll for reimbursement in the next regular,
scheduled payroll run. Reimbursements will be sent to the traveler’s address on record via payroll with paycheck or direct deposit.
Please indicate the Trip # and Pers# above for reference. These numbers can be found on your Approved Travel Request Notification (ATRN).
Invalid or blank Trip# and Pers# may delay your reimbursement.
Expenditures paid by the P-Card, Recruiter Card and Travel Credit Card (T-Card) are not reimbursable. Only District approved self-paid travel
expenses are reimbursable. Attach copies of any special approvals (e.g., memos, side letters, etc.) provided for exceptions to travel policies.
EXPENSES: *Receipts required. Complete the applicable reimbursable amounts below; all
expenses related to this travel must be entered.
PREPAID
REIMBURSABLE*
1.
Airfare:
T-Card
self-paid
Airline
$
$
2.
Baggage:
T-Card
self-paid
$
$
3.
Conf. Fee:
P-Card
self-paid
Imprest
PO/Shopping Cart
$
$
4.
Conf. Room:
self-paid
$
$
5.
Per Diem:
# of Days _____
# of Full Days ___
# of Half Days ____
Per Diem is only allowable if travel
is beyond 45 miles from workplace
$
$
6.
Gas:
self-paid
$
$
7.
Hotel:
T-Card
self-paid
#of Days __
Hotel Name: ________________________
$
$
8.
Miscellaneous:
T-Card
self-paid
$
$
9.
Parking:
T-Card
self-paid
$
$
10.
Postage/Shipping
T-Card
self-paid
$
$
11.
Car Rental:
T-Card
self-paid
# of Days __
District Paid _______________________
$
$
12.
Substitute:
District Paid
Outside Agency
Agency Name ___________________
# of Days ___
$
$
13.
Taxi/Shuttle:
T-Card
self-paid
$
$
15.
Mileage
# of Miles (Round Trip): _____
$
$
TOTAL TRAVEL CLAIM:
TOTAL(S):
$
$
Expense Budget Line:
%Distribution
Cost Center
Order
WBS Elem
Fund
Grant
Functional Area
%Distribution
Cost Center
Order
WBS Elem
Fund
Grant
Functional Area
AFFIDAVIT:
Employee Name:
Employee Number:
Job Class Code:
Title:
LD Office:
School/Office Name:
Work Telephone No:
Fax
Email
Executed this month of:
Day of:
__________, 20___
at:
I declare under penalty of perjury that the foregoing is true and correct.
Traveler:
(Name)
(Signature)
(Date)
Approved by:
(Print Name/Title)
(Signature)
(Date)
Approved by:
(Print Name/Title)
(Signature)
(Date)
0.00
0.00
0.00
0.00
0.00
O
(For Rental Cars ONLY)
CANCEL REQUEST:
Trip Cancelled
Event Cancelled
Traveler No-Show
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