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
Are you requesting this reimbursement on behalf of someone else?
Payee (if other than requestor)
i.e., county juvenile probation office
Payee Email
example@example.com
Remittent Address

Mailing Address to send payment to

Address Line 2

CityState / Province

Postal / Zip Code
Vendor Number
Please provide your 5 digit vendor number provided by the Idaho State Controller's Office & PaymentWorks
Reimbursement Information

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

MonthDayYear
Date
Reason for Request or Purpose of Travel
Please select all items you are requesting reimbursement for

Other
Please select if you are requesting per diem/lodging for in state or out of state travel
If you are not requesting reimbursement of mileage, meals, lodging, 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.

Travel Expenses

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

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). Breakfast is allowable if leave at or before 7 am or return at 8 am or later; Lunch is allowable if leave at or before 11 am or return at 2 pm or later; Dinner is allowable if leave at or before 5 pm or return 7 pm or later. For full day per diem (all meals), only select "Full Day". Note that if the full day box is checked in addition to individual meal options, IDJC staff will adjust your totals to reflect policies/accurate totals.

Rows	Date	Breakfast	Lunch	Dinner	Full Day	Lodging City	Lodging Cost
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). Breakfast is allowable if leave at or before 7 am or return at 8 am or later; Lunch is allowable if leave at or before 11 am or return at 2 pm or later; Dinner is allowable if leave at or before 5 pm or return 7 pm or later. For full day per diem (all meals), only select "Full Day". Note that if the full day box is checked in addition to individual meal options, IDJC staff will adjust your totals to reflect policies/accurate totals.

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

Additional Reimbursement Items:

Please note: all requested items must be validated through documentation (receipts, etc.).
I am requesting reimbursement on additional and/or miscellaneous items.
Parking
Commercial Airfare
Ride Share/Taxi
Misc.
Registration costs, etc.
Please provide any additional details that will help validate your additional and/or miscellaneous items for reimburement.
NOTE: State of Idaho Travel Policies now allow Taxi, rideshare, and similar transportation tips to be reimbursable up to 20% of the fare when documented and reasonable. Receipts or similar documentation must be provided to verify the cost.
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 (Partial Days, OUT OF STATE ONLY)
Total Per Diem Reimbursement (Full Days, 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
Should be Empty:

Request for Reimbursement

Instructions:

Requestor Information

Reimbursement Information

Total Reimbursement for Request

Supporting Documentation