Free Non-State Employee Travel Reimbursement Request, F-80190 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Enterprise Services F-80190 (Rev. 04/09)

STATE OF WISCONSIN

NON-STATE EMPLOYEE TRAVEL REIMBURSEMENT REQUEST
Invoice Number Month / Year Invoice Amount Invoice Type Blank = normal 2 = credit 3 = manual

NOTE: For assistance in completing this form, contact your supervisor. FY Travel Voucher Number Vendor Number

T
Org. No. Organization Name Name ­ Claimant

Home Address ­ Claimant (Complete)

Audit pursuant to Chapter 16, of the Wisconsin Statues and allowed in accordance with the provisions of Chapter 20 as shown. Certified to the State Treasurer payable from the Fund shown. SIGNATURE Date Signed

1.

GENERAL INSTRUCTIONS a. b. c. This form is intended for NON-EMPLOYEES of DHS and attached Boards Print legibly using black or blue pen or type. After completing and signing your travel voucher, SUBMIT ORIGINAL, to your supervisor or coordinator for signature. Retain one copy, if you wish, for your personal records. Staple required receipts to the itinerary side, where indicated. Receipts are required for lodging and for other items identified in the Pocket Travel Guide. Receipts must be original. CREDIT CARD SLIPS ARE NOT ALLOWED.

Line

Apptn.

Account

Center

Amount

Sign Code

Error Message Code

1 2

21600

d.

2.

3 4 5 6 7 8 9 10 11 12 13
4.

REQUIRED INFORMATION: All applicable itinerary information must be completed, including claimant and supervisor signatures, plus the following side information. a. b. c. d. Claimant's Vendor Number Organization Number and Name Claimant's Name (Legibly Printed) Claimant's Home Address

NOTE: Vendor Number information is required for payment and 1099 processing. If Vendor Number information is not provided, delays in payment processing can occur. 3. MEALS INCLUDING TIPS: Record actual reasonable and necessary out-of-pocket expenses incurred for meals in the performance of official duties. The expense amount (including tax and tip) should not exceed maximum rated allowed. ** PERSONAL VEHICLE USE a. b. Record round trip mileage between starting point and destination Mileage should be claimed at amount shown in the "Pocket Travel Guide".

** See "Pocket Travel Guide" for a summarization of the state's travel guidelines and allowable maximums.

KEYERS ONLY Entered By

Date ­ Entered



STAPLE RECEIPTS HERE ­ FACE UP Headquarters City Date Mo. / Day OFFICIAL BUSINESS (Clearly explain purpose of trip) ITINERARY From To HEADQUARTERS TIMES Leave am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm TOTALS Return am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm Miles @ Miles @ Miles @ addl. SIGNATURE ­ Supervisor (Indicates "OK to Pay") TRANSPORTATION Miles Fare

NOTE: Identify all items billed directly to the Department with an asterisk (*)

LODGING

MEALS, INCLUDING TIPS Morning Noon Evening

OTHER ALLOWABLE EXPENSES Item Amount

TOTAL EXPENSE

CLAIMANT'S STATEMENT, s. 16.53, Wisconsin Statutes I declare, under penalties of perjury, that the above expenses (Including mileage) were incurred in conformity with applicable statutes and regulations. These are actual, reasonable and necessary expenses incurred personally in the performance of duties required by public services. Payment, credit, or free service has not been received from any source except for reported travel advances. SIGNATURE ­ Claimant Date ­ Signed

I certify I have reviewed this travel claim and find it to be reasonable, proper and in conformity with applicable statues and travel schedule amounts.

cents per mile = cents per mile = cents per mile = Date ­ Signed Total Expenditures Total Mileage Cost

Net Amount Due