Request for Reimbursement of Travel Expenses

NORTH CAROLINA LIBRARY ASSOCIATION

Date: _________________

Name: __________________________________ Phone: ___________________

Address: __________________________________________________________

City: ___________________________State: _____________Zip:_____________

Section, Round Table, Committee, etc.:_________________________________

Destination: ________________________________________

Purpose of Trip(s): ___________________________________

Summary of Reimbursable Expenses

In-State/Out-of-State

Meals

Breakfast(s) $ 7.00/7.00 X ___ = $_____

Lunch(es) $ 9.25/9.25 X ___ = $_____ 

Dinner(s) $15.75/17.75 X ____= $_____ 

Transportation: _________________________________________$_____

Lodging (attach receipt): $59.75/71.00 $_____

Registration (attach receipt): $_____

Mileage $.485 X ____ miles = $_____

Other (explain & attach receipts):$_____

Total Due $ _____

SUBMITTED FOR PAYMENT ______________________________________

Signature of Requestor Date

APPROVED FOR PAYMENT ________________________________________

Signature of Chair or President  Date

(Do not write in this space – For use by Treasurer only)

Check Number : ____________________________ Date _____________

Budget/Fund: ______________________________________________

Signature of Treasurer

rev. 2005-11-14