Per Diem in Advance Request Form
As of 2023, IHSA Board members may request per diem to be issued in advance, should awaiting a reimbursement cause financial hardship. Please request your advanced per diem at least two weeks ahead of the eligible meeting.
Name
First Name
Last Name
IHSA Role (example: IHSA Board Parent Rep)
Purpose of Travel (IHSA Board meeting, RXHSA Board meeting)
Travel Destination
Mailing Address to Receive Check
Departure Date
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Month
-
Day
Year
Date
Return Date
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Month
-
Day
Year
Date
Estimated Departure Time & Return Time
Per diem items being requested in advance (mileage, meals & incidentals, rideshare fees, parking fees, childcare). Please include the estimated cost for each, using the current GSA mileage rate found on GSA.gov, the M&I rate for the appropriate city found on GSA.gov, and the IHSA childcare reimbursement policy provided by the executive director.
I hereby certify that the above information is true and accurate to the best of my knowledge. I understand that any false statements or misrepresentations may result in disciplinary action.
Date Signed
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Month
-
Day
Year
Date
Executive Director Signature
Date Signed
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Month
-
Day
Year
Date
Submit
Submit
Should be Empty: