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.

Policies for Reimbursement
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?*

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
I am requesting reimbursement for travel expenses

YesNo

Travel Expenses

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

I am requesting reimbursement for lodging and/or meal expenses

YesNo

Lodging & Meal Expenses (please select the items you are requesting for reimbursement). Please note, if you traveled outside of Idaho, IDJC Staff will adjust your auto-calculated per diem to match current GSA rates. 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".

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

I am requesting reimbursement on additional and miscellaneous items.

YesNo

Total Reimbursement for Request

This section will auto-calculate based on your responses.
Total Mileage Reimbursement ($0.70/mile)
Total Per Diem Reimbursement
Total Lodging Reimbursement
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.
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:

	$ Amount
Parking
Commercial Airfare
Miscellaneous

Request for Reimbursement

Instructions:

Requestor Information

Reimbursement Information

Total Reimbursement for Request

Supporting Documentation