Employee # * Name * Residence * Work Station *
6/24/2005
Paygroup *
STATE OF VERMONT
REIMBURSEMENT OF TRAVEL EXPENSE FORM
Pos #> *
NAME OF DEPARTMENT
Rev. 9/1/2005 Form No APER10
Page 1 of 1
Clear Form
GRAND TOTAL
7
YEAR
LINE #: 1 2 3 4
5
6
8
9
LINE
Paper Users write ''mm/dd''
DATE* TOTALS FUND DEPT ID
CHART OF ACCOUNT CODES
PROG CLASS PROJECT/GRANT
CODES
ENTER NUMBER OF MILES ONLY IN THIS SECTION
MILES
CODES
ENTER AMOUNT OF REIMBURSEMENT REQUESTED
AMOUNT
column # #
1 2 3 4 5 6 7 8 9
List Towns or Cities to which you traveled (*If meals taken)
Explain Business Purpose or Reason for Travel Expense
Departed
TIME
Returned
WE THE UNDERSIGNED CERTIFY UNDER THE PENALTIES OF PERJURY THAT THE INFORMATION GIVEN ON THIS FORM REPRESENTS THE ACTUAL EXPENSES TO WHICH THIS EMPLOYEE IS LEGALLY ENTITLED Employee Signature
LODGING RT = OUT-OF STATE RM = IN-STATE MEALS: "BREAKFAST" BT = OUT-OF-STATE TAXED XB = OUT-OF-STATE NOT TAXED BM = IN-STATE TAXED BX = IN-STATE NOT TAXED MEALS "LUNCH" LT = OUT-OF-STATE TAXED XL = OUT-OF-STATE NOT TAXED LM = IN-STATE TAXED LX = IN-STATE NOT TAXED
Date
Supervisor Signature
MEALS "DINNER" ST = OUT-OF STATE TAXED XS = OUT-OF-STATE NOT TAXED SM = IN-STATE TAXED SX = IN-STATE NOT TAXED OTHER CODES MM = MILEAGE IN-STATE MT = MILEAGE OUT-OF-STATE CT = INCIDENTALS OUT-OF-STATE CM = INCIDENTALS I N-STATE PT = OUT-OF-STATE PM = IN-STATE
Date
OTHER TRANSPORTATION