Travel Expense Reimbursement Form

Travel Expense Reimbursement Form
This form is used for expenses related to authorized travel on behalf of Ozark Swimming. Please refer to the Ozark Swimming Travel Reimbursement Policy.

GSA Per Diem: Please enter the year and location and select "Find Rates." Scroll down to "Meals and incidental expenses (M&IE) rates and breakdown." You will use the amount listed under the M&IE Total column.

This form must be completed within 30 days of travel.

Need help or have questions, contact treasurer@ozarkswimming.com
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Name of Event, Meet, Conference, etc.*
Location*

Street Address

Street Address Line 2

CityState

Zip Code
First Day of Travel*

MonthDayYear
Date
Last Day of Travel*

MonthDayYear
Date
Expenses

Fill out the items below for any expenses you personally paid and are seeking reimbursement. Attach any applicable receipts (pdf preferred) in the documentation section.
Airfare/Miscellaneous Travel Expenses:

Must provide receipts under Documentation

Details of Airfare/Miscellaneous Travel Expenses:

	Description	Amount
Airfare
Rental Car
Parking Fees
Uber/Rideshare
Baggage Fees
Tolls
Other

Total Airfare/Miscellaneous Travel Expenses:
Per Diem (Meals & Incidental Expenses):
GSA Per Diem Rate $ (M&IE): (Must use the applicable GSA Rate from link listed above)
Did your first day of travel require departure before noon?

YesNo
Did your last day of travel require travel past noon?

YesNo
Trip Days:
First Day Factor
Last Day Factor
Middle Days Count
Per Diem Total ($)
# of Full Days Spent at the Event:
# of First/Last Travel Days: (If your first day of travel did not require travel before Noon,
Total Per Diem ($):
Mileage Reimbursement

(Personal Vehicle Use) Note: Mileage reimbursement is subject to a cap based on the cost of the most economical travel option (e.g., airfare plus rental car if applicable). Reimbursement may be adjusted to the lower of actual mileage or equivalent airfare + ground transport.
Miles Driven (round trip total in miles):
GSA Mileage Reimbursement Rate ($ per mile):
Total Mileage Reimbursement ($):
Stipend:

Please note: Amounts over $600 will require issuance of a 1099
Stipend $ (if applicable):
GRAND TOTAL($):
Grand Total Reimbursement ($):
Further Explanation:
Please provide any other details that may be helpful in processing your request. If asked for more information by the approver, please provide answers here.
Remittance:

Please provide to whom to send reimbursement.
Make Check Payable to:*
Send Check to:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
New Address

Check if this is a new address.
By signing below, you attest that all information provided in your request is true and accurate, that this travel was pre-approved, and that all expenses submitted comply with the Ozark Swimming Travel Expense Reimbursement Policy.
Signature*

Clear
Name of Signer*

First NameLast Name
Documentation

PDFs are preferred for all documentation.
Please provide the following documentation:

For all receipts, be sure it is a receipt and not just a credit card receipt. The receipt must show what was purchased or paid for.

Travel Expenses
- Airfare receipts
- Other Travel Receipts (including rental car, parking fees, Uber/Rideshare, bagge fees, tolls, etc.)
- You do NOT need receipts for per diem and mileage.
Receipts

Cancelof
Any Additional Documentation

Cancelof
Admin Section
Reimbursement Reviewed and Approved:

Yes, as submittedYes, adjusted (see explanation below)No, denied (see explanation below)
Explanation:
Should be Empty:

Travel Expense Reimbursement Form

Expenses

Airfare/Miscellaneous Travel Expenses:

Per Diem (Meals & Incidental Expenses):

Mileage Reimbursement

Stipend:

GRAND TOTAL($):

Remittance:

Documentation

Admin Section