Reimbursement Request Form

Request for Reimbursement

Please submit this form within ten (10) calendar days of return from travel status or expense.
Instructions:

All supporting documentation (e.g., receipts, maps to verify distance, training requests, etc.) must be submitted with this application.

State of Idaho Travel Policy and Procedures: https://www.sco.idaho.gov/LivePages/State-Travel-Policy-and-Procedures.aspx

Out of State Rates: https://www.gsa.gov/travel/plan-book/per-diem-rates

Requestor Information
Requestor Name

First NameLast Name
Requestor Email
example@example.com
YesNo
Payee (if other than requestor)
i.e., county juvenile probation office
Payee Email
example@example.com
Vendor Number
Please provide your 5 digit vendor number provided by the Idaho State Controller's Office
Reason for Request or Purpose of Travel*
Reimbursement Information

Please enter information specific to your reimbursement. IDJC may make adjustments as required for travel policies.
Date of Request

MonthDayYear
Date
YesNo
If you are not requesting reimbursement of mileage, meals, or travel, please explain why.*
Brief description (stayed with family, paid by another party, etc.)
NOTE: You must provide travel information to include the date, destination information, departure and arrival times to ensure accurate reporting of per diem. Incomplete information may delay your reimbursement.

In state (Idaho only)Out of State
What is the full per diem found on GSA.gov?
Per diem is based on the percentage of this rate, per State of Idaho Travel Policies.

IDAHO TRAVEL ONLY: Lodging & Meal Expenses (please select the items you are requesting for reimbursement). For breakfast, you must arrive before 7 am; lunch before 11 am; dinner before 5 pm. If you are requesting per diem for the full day, only select "Full Day".

Rows	Date	Breakfast	Lunch	Dinner	Full Day	Lodging City	Lodging Amount
1
2
3
4
5
6
7
8

OUT OF STATE TRAVEL ONLY: Lodging & Meal Expenses (please select the items you are requesting for reimbursement). For breakfast, you must arrive before 7 am; lunch before 11 am; dinner before 5 pm. Per diem is based on the percentages of the full date per diem you provide in the last column on the right.

Rows	Date	Breakfast (25%)	Lunch (35%)	Dinner (55%)	Lodging City	Lodging Amount
1
2
3
4
5
6
7
8

YesNo

Total Reimbursement for Request

This section will auto-calculate based on your responses.
Total Mileage Reimbursement ($0.70/mile)
Total Per Diem Reimbursement (IDAHO ONLY)
Total Per Diem Reimbursement (OUT OF STATE ONLY)
Total Lodging Reimbursement (Idaho)
Total Lodging Reimbursement (Out of State)
Total Additional Requests
TOTAL REIMBURSEMENT REQUEST
Supporting Documentation

Please upload all supporting documentation for your requested reimbursement. Please include event agendas, receipts, maps indicating distance, etc. Any missing documentation may delay your reimbursement.
Reimbursement Documentation Upload

You can upload multiple files at once.
Cancelof
If applicable, please upload the corresponding approved RFF from the District Council.

Cancelof
By signing, I hereby certify that the amounts set out in the Request for Reimbursement are correct and just, and that I have not received previous payment.
Signature*

Clear
Should be Empty:

Rows	Date	Destination From	Destination To	Distance	Departure Time	Arrival Time
1
2
3
4
5
6
7
8

Rows	$ Amount	Notes/Details for Validation
Parking
Commercial Airfare
Miscellaneous

Request for Reimbursement

Instructions:

Requestor Information

Reimbursement Information

Total Reimbursement for Request

Supporting Documentation