INTERNATIONAL TRAVEL REIMBURSEMENT claim FORM

Form and receipts must be submitted within 45 days of expenditure

Date:
Preparer:

Dept.:

If we have questions, who should we contact? Payee:

PAYEE

Preferred Contact Info. (if not Payee): Name:

UC Employee:

Email:

Phone:

Student:

Vendor:

Other:

Phone:

Email:

Name:
US Citizen/Permanent Resident? Yes

Preparer:

Emp/Stu/Vend.ID:

Other:

Org.Node:

Address:
If no, you will be contacted by CSS for more info. e.g. Passport, I-94,UC-W8-BEN,COAA

No

TRIP

Business Purpose: State date(s), location(s) and reason(s):

Details for any Personal Time, Entertainment or Special Circumstances: Enter date(s), location(s). For entertainment, also include business
purpose, guest names & their affiliation. Enter meal costs in M&IE section blw.

TRANSPORTATION & MISC. EXPENSES

Air Fare: Seeking Reimbursment? No

Yes

(If Direct Bill attatch Connexxus Itinerary)

Direct Bill? Yes
Attatch Itinerary & Proof of Payment
Airfare Amount:

Personal Car: Standard Mileage Rate is 54.0 cents for travel on or after January 1, 2016
Drove To Address
Drove From Address
Date

Rate

Miles

Amount
0.00
0.00
0.00
0.00

Rental Car: Economy/Compact/Intermediate

Reason for "Other Size" Car:
Transportation & Other Misc. Expenses:
Taxi
Gas
Parking
BART/Rail

Toll

Taxi

Total Mileage Amount:

Other Size

Car Rental Amount:

Shuttle

Baggage

Shuttle

Other

Conference/Registration Fee: Seeking Reimbursment? No

Paid on Blue Card?* No
Optional Notes/Comments:

$0.00

0.00

Yes
Yes

Other

Tips
Tips

Phone
Internet

(non meal)

Other

Conference/Registration Fee Amount:

*(If paid on bluCard, do not enter amount)

$0.00

LODGING, M&IE EXPENSES

TOTAL TRANSPORTATION & MISC. EXPENSES:

Lodging, Meals & Incidental (M&IE): Travelers should only claim Actual Expenses up to Federal Per Diem Rate for the locality of travel.
If additional space is needed, either attach another "daily expense" section or your own detailed spreadsheet of expenses.

Dates

Currency

Location

Lodging

Breakfast

Optional Notes:
Travel Advance Amt: Enter (-) amt:

Travel Advance? Yes

Fund

CERTIFICATION

COA

Account

Dept

Program

Dinner

Light Ref

M&IE TOTAL:
LODGING & M&IE TOTAL:

$0.00

LODGING TOTAL:

Lunch

ESTIMATED REIMBURSMENT:
CF 1

CF 2

$ Amount

M&IE Totals
0.00
0.00
0.00
0.00
0.00
0.00

$0.00
$0.00

$ 0.00

Optional: Chartstring Description

Accounting Approval (Dept Specific)

I certify that the above is a true statement, that the expenses claimed were incurred by me on official University business
on the dates shown, and that I have attached original receipts for each expense as required by University policy.
Traveler Name andTitle:
Traveler Signature:
Authorizing Name and Title:
Authorizing Signature:

Date:
Date:
02/02/2016