Expense Reimbursement Form

SJCPHD1 — Expense Reimbursement Form

Employee Name

Date Submitted

Travel Reason / Destination

Meals

Start

Date (mm/dd/yyyy)

Time

End

Date (mm/dd/yyyy)

Time

Breakfast

—

Lunch

—

Dinner

—

Meals Total

$0.00

Lodging

Number of Nights

Default — $175 / night $0.00

$220 / night

(Agency Head approval)

$0.00

Custom rate

$/night

(Agency Head approval + receipt)

$0.00

Lodging$0.00

Transportation

Mileage × $0.70 (map required)

Miles

Amount

$0.00

Ferry Ticket receipt required — personal or agency vehicle

Amount

Parking receipt required

Amount

Airfare receipt required

Amount

Excess Baggage receipt required

Amount

Uber / Taxi / Mass Transit receipt required

Amount

Car Rental / Gas receipt required

Amount

Transportation$0.00

Miscellaneous (receipts required unless noted)

Date (mm/dd/yyyy)	Description (OTEP $120 — no receipt needed)	Amount

Misc$0.00

Total Reimbursement $0.00

I swear that the above expenses are true as stated, and that the expenses charged were necessary and approved prior to expenditure.

Signature of Claimant

Signature of Agency Head