LTAI Scholar Reimbursement Form FY25

Disbursement Form - ICfL Staff Use Only
LTAI Scholar Travel Reimbursement
Project Number:
Project Title:
Fund:
Funding Source:
Appropriation Unit:
Account Code:
Check / Invoice Description:
Staff Approval Signature:
Scholar Reimbursement

Please submit a reimbursement form for each LTAI session
Before completing the form, please:
- Review the ICfL's Scholar Invoice Rates & Instructions for reimbursement guidelines and allowable expenses
This form must be submitted within four weeks of the LTAI session.
Claimant Information
Make Check Payable to:*
Mailing Address of Individual Receiving Check:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please make sure you have a completed W-9 on file. We require updated W-9s yearly. A check will not be issued unless a current W-9 is on file due to State of Idaho requirements.
W-9 for Party Receiving Reimbursement:*

I plan to email a W-9 to: josephine.bradford@libraries.idaho.govI plan to mail a W-9 to: Fiscal Department, Idaho Commission for Libraries, 325 W State St.Boise, ID 83702I already have a W-9 on file
Full Name of LTAI Scholar*
Library hosting the LTAI session (choose one):*
You must submit a separate form for each event attended.
Scholar email address:*
example@example.com
Scholar phone number:*

Area CodePhone Number
Date and time of LTAI session*

MonthDayYear
DateHourMinutesAM/PM Option
Would you like to claim a $250 speaker fee for this session? If yes, select 250:*

2500
I would like to claim meal/travel/lodging costs*

YesNo
Travel Details
Mode of Travel*

Air TravelGround Travel
Ground Travel
Mileage:

Use Google Maps to calculate mileage.

Mileage and drive time are calculated from your home city to the location you did your LTAI presentation. Use the shortest, safest route.
ONE-WAY Mileage from home city to LTAI presentation site *Use Google Maps
Enter one-way mileage
Total Mileage (automatically calculated)
Mileage Reimbursement Amount Claimed (automatically calculated, do not enter a value)
Mileage Claimed multiplied by $0.67/mile.
Air Travel
Airfare cost:
Upload receipt below
Baggage fee:
Upload receipt below
Shuttle/taxi to and from airport to event (if not provided by hotel):
Upload receipt below
Receipts must be received within two weeks of submitting this form.*

I plan to email my receipts to: josephine.bradford@libraries.idaho.govI will upload my itemized receipts
Upload receipts (if possible, scan all receipts into one file, then upload)

Browse Files
Individual files are also accepted: pdf, doc, docx, jpg, jpeg, png. If you cannot get this widget to work, you can email receipts to the ICfL staff person who coordinated your event. Cancelof
Mileage to and from airport:

Use Google Maps to calculate mileage and drive time for questions below.

Mileage and drive time are calculated from your home address to airport. Use shortest, safest route.
ONE-WAY Mileage to airport from my home address, according to Google Maps:
One-Way
ROUND-TRIP Mileage to Airport (Automatically Calculated, DO NOT ENTER A VALUE):
Mileage Reimbursement Amount to/from Airport (automatically calculated, do not enter a value)
Lodging

Lodging will be reimbursed at actual cost. An itemized receipt issued by the hotel showing check-in/check-out dates is required (not a credit card receipt). Lodging should be secured at standard rates for the area. Unusually expensive/luxury accommodations or excessive lodging costs (such as additional rooms for family members) are not allowable. The ICfL will not reimburse travelers for additional expenses such as in-room movie rentals, laundry services, or room service.
Did you require lodging?*

YesNo
Total lodging reimbursement amount you wish to claim:
This amount needs to be reflected in the receipts
Lodging receipts must be received within two weeks of submitting this form.*

I plan to email my itemized receipt to: josephine.bradford@libraries.idaho.govI will upload my itemized receipt *see below
Upload receipts (if possible, scan all receipts into one file, then upload)

Browse Files
Individual files are also accepted: pdf, doc, docx, jpg, jpeg, png. If you cannot get this widget to work, you can email receipts to the ICfL staff person who coordinated your event. Cancelof
Meal Stipend

I would like to claim the following meals *Please refer to the chart above to make sure you qualify for each meal.*

BreakfastLunchDinnerOr I qualify for the full day.Or I do not wish to claim per diem meals.
Total meal reimbursement (automatically calculated, do not enter a value):
Please include any comments or clarification regarding your travel-related reimbursement, if needed:
Miscellaneous Expenses: These expenses must be cleared with the ICfL BEFORE they are incurred.
In-Kind Match Hour

Scholars are asked to contribute their time spent preparing for and traveling to each session as an “in-kind” donation to the program. The ICfL will calculate the estimated value of these hours and will report this as an in-kind match as required by funders and other partners. You will not be reimbursed for in-kind hours.
How many hours did you spend preparing for the LTAI session?
Program prep will be calculated at a rate of $50 per hour.
How many hours did you spend traveling to and from the program?
Travel time will be calculated at a rate of $10 per hour.
Signature
Don’t forget to submit a LTAI Scholar Feedback Form after each session. Payment may be delayed or held until a feedback form is completed.

If you have any questions about this form, please contact LeAnn.Gelskey@libraries.idaho.gov

Itemized Expenses:

Mileage Reimbursement Total: ${mileageReimbursement}	Airfare: ${airfareCost}
Meal Stipend: ${totalMeal}	Baggage Fee: ${baggageFee}
Speaker Fee: ${wouldYou}
Lodging: ${totalLodging}	Shuttle from airport to event: ${shuttletaxiTo}
	Mileage Reimbursement Amount to/from Airport: ${mileageReimbursement88}

Total Reimbursement Claim:
Travel Total:
Your typed name in the box below serves as your signature.*

First NameLast Name
When you click "submit" you will receive an email copy of this form.
Should be Empty:

Meal	Rate	On Departure Date	On Return Date
Breakfast	$13.75	Must leave home before 7 a.m.	Must arrive home after 8 a.m.
Lunch	$19.25	Must leave home before 11 a.m.	Must arrive home after 2 p.m.
Dinner	$30.25	Must leave home before 5 p.m.	Must arrive home after 7 p.m.

Disbursement Form - ICfL Staff Use Only

Scholar Reimbursement

Claimant Information

Travel Details

Ground Travel

Air Travel

Lodging

Meal Stipend

In-Kind Match Hour

Signature