NCSU-CVM/MBS Dept. Travel Reimbursement Claim Form TR/V# (for office use only)______

Name: / Email
Destination / Employee ID(required)
Account #
1. Actual dates of travel (include any vacation days)
2. If vacation taken, which dates did you attend the meeting?
3. Time of departure for the trip? / AMPM / (circle one)
4. Time of return from the trip? / AMPM / (circle one)
  1. Lodging:
(submit original receipt of actual lodging expenses from acommercial lodging establishment
In-state$65.90 / Out-of-state$78.05 / # of night / $ per night per night / Total Lodging Lodging
6. Was lodging shared? If so, pleaselist namesindicate if they are also state employees.List their dept. in order to cross reference their travel. Additionally, please indicate your portion of the lodging expense.
ROOMMATE NAME / STATE EMPLOYEE?
Yes No / Department
# of night / $ per night per night / Total Lodging:$ Lodging
7. Were there any meals included in the registration feeat the conference? / If yes, please list below:
Date(s) - Meal(s):
Total meal reimbursement - see pg 2 for per diem info. Subtract any meals included in registration fee) ) / $
8. Personal Car Mileage Claim: / $
# of Miles Round Trip / X 0.25 mile / Total Mileage
$
# of Miles Round Trip / x .445/mile = / Total Mileage
9. Airfare Amount: / $ / Prepaid/Pre-Reimbursed / Yes No / (circle one)
10. Registration fee: / Prepaid/Pre-Reimbursed / Yes No / (circle one)
11.Original, itemized receiptsrequired for all of the following:
Use of taxi service / $
Road, bridge, or ferry tolls / $
Use of airport limo service / $
Use of rental car / $
Garage/Parking lot charges / $
Total Other: / $
If foreign travel was incurred what currency of money was used?
Please turn in all original, itemized receipts when applying for reimbursement (except meals).

Per Diem Information:

In-State Food Allowance / Breakfast $7.50 x ____ days (before 6 am on day 1) =
Lunch $10.10 x _____ days (if more than 1 day trip) =
Dinner $17.30 x _____ days (after 8 pm on last day) =
Out-Of-State Allowance / Breakfast $7.50x _____ days (before 6 am on day 1) =
Lunch $10.10 x ______days (if more than 1 day trip) =
Dinner $19.65 x _____ days (after 8 pm on last day) =
Out-Of-Country Allowance / Breakfast $7.75 x _____ days (before 6 am on day 1) =
Lunch $10.10 x _____ days (if more than 1 day trip) =
Dinner $19.65 x _____ days (after 8 pm on last day) =
Subtract any meals included in registration/provided on airplane/ or provided by sponsor :
Total:

Total Amount of Reimbursement: $ ______.____

Were you paid an honorarium or fee?_Y or N
Signature of traveler ______

For Foreign National visitors:

If International visitor, please provide the following documents dependent upon the VISA type:

-B1 : Passport Issue Page, VISA page, Form I-94 or Passport Stamp
B1/B2: Passport Issue Page, VISA page, Form I-94 or Passport Stamp

-B2: Passport Issue Page, VISA page, Form I-94 or Passport Stamp

-H1B: Passport Issue Page, Current VISA page, Form I-94 , Form I-797

-J1: Passport Issue Page, Current VISA page, Form I-94, Form DS-2019

-WB: Passport Issue Page, Form I-94 or passport stamp

-WT: Passport Issue Page, Form I-94 or passport stamp

If from Mexico/Canada, please provide a copy of your passport.

Or if you hold the following VISA type, please provide:

- TN: Passport Issue Page, Form I-94

Revised December 7, 2010