Division of Emergency Medicine

Reimbursement Request: TRAVEL

NAME of Traveler / Today’s DATE
FUNDING SOURCE
☐Academic Enrichment Fund - If yes, give date Dr. Stern/Jeff Bronstein were notified:
☐ Start Up - Budget Number:
☐ Grant - Budget Number:
☐ Other * (Specify Name & Number):
DESTINATION
DATES of Travel
CONFERENCE/MEETING ATTENDED (spelled out)
PURPOSE of Trip
If GRANT funded, explain how the grant has benefited:
ITINERARY - Attach detailed air itinerary with dates, times, flight numbers etc. For travel to destination by other method give details:
PERSONAL LEAVE TIME TAKEN? No ☐ Yes ☐ Give the dates and time personal leave began and ended along with location specifics:
COSTS, such as meals, included in registration or paid by others ? No☐ Yes☐ Provide details:
Does LODGING cost exceed the destination city’s allowable rate ? No☐ Yes☐ Attach documentation and provide details:
EXPENSE SUMMARY
List expenses (other than meals) such as:
Registration, Airfare, Lodging, Parking, Ground Transportation (taxi, shuttle etc.), Car rental. (Continue on next page if needed.)
Original receipts are required for:
Expenses exceeding $75 and—regardless of cost—for airfare, lodging, registration, car rental, laundry, meals paid on behalf of others.
Meal per diem will be automatically calculated and paid based on your itinerary, personal time and meals paid by others. / DATE / DESCRIPTION / COST
(Excluding meal per diem) SUB TOTAL
(Automatically added by Fiscal Specialist) MEAL PER DIEM
T O T A L $
PRIVATE AUTO MILEAGE Select one of the following, attach MapQuest driving directions, including mileage. / From:
Address/Zip
1. ☐ Point-to-point(driving to one destination using most direct route) miles at $0.575 (1/1/2015) = $ / From:
Address/Zip / To:
Address/Zip
Outbound / From: Address / To: Address
Return / From: Address / To:Address
2. ☐ Vicinity (Driving to several destinations.) Attach odometer/mileage log. miles at $0.575 (1/1/2015) = $
RETURN THIS FORM within 30 days of purchase to ensure reimbursement. Remit along with required receipts and documentation, to EM Finance, Box 359702, HMC 3EC-22, (206) 744-4099.
Required attachments checklist:
☐ Original receipts or completed UW Perjury Statement.
☐ Detailed itinerary with dates, locations, times, flight #s.
☐ Documentation for lodging price above allowable rates.
☐ Link/web address to conference brochure:
______/ * If Funding Source is Other, Department Head or Administrator signature is required.
Approver Signature______
Print Name ______

2015.06.30 H:\ajillc Jill Christenson\1 FINANCE\Reimbursement info and forms\REIMBURSEMENT REQUEST_TRAVEL.docm