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STATEMENT OF TRAVEL EXPENSES
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Employees must submit this form and original receipts within 30 working days after return from travel
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in order to be reimbursed. Please attach receipts to separate sheets of paper. This claim will include all
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actual out-of-pocket expenses. No foreign travel is allowed or reimbursed by the ESSA grants.
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NAME:Vendor Number
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ADDRESS:Email:
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SCHOOL:
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ACTIVITY:
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LOCATION OF ACTIVITY (City, State):
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DATES OF ACTIVITY (Inclusive):
NUMBER OF DAYS:
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Airfare ……………………………………………………………………………………
$
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Automobile (No. of Miles)
$ 58.5 cents/mile (2022 IRS Rate)
$
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Bus Fare …………………………………………………………………………………
$
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Parking: $25.00 limit per day
$
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Cab Fare …………………………………………………………………………………
$
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Other (Specify)
………………………………………
$
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Hotel/Motel ………………………………………………………………………………
$
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Meals ……………………………………………………………………………………..
$
Not Reimbursed
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Registration Fee ………………………………………………………………………..
$
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Miscellaneous Expenses (Specify)
………………..
$
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TOTAL ……………………………………………………………………………………
$
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RULES
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1.
Automobile mileage reimbursement is pre-authorized between the following locations:
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a.
School work site and commercial transportation terminal.
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b.
Commercial transportation terminal and lodging or conference site.
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c.
Conference site and lodging (if separate)
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2.
Commercial transportation reimbursement is pre-authorized for coach fare; original receipt must be attached.
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3.
Hotel reimbursement is allowed only if the distance to the location is more than 50 miles.
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4.
Lodging reimbursement is pre- authorized for standard single economy room rate only, unless government,
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corporate, or conference discounted rate is available and less than the standard single room rate.
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Applicant Signature:Date:
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CPS Approval Signature:Date:
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FOR CPS USE ONLY
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UnitFundAccountProgramGrant
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For all reimbursement requests, please retain copies of this completed form and all receipts for your files.
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Send this original form, with receipts attached to a separate sheet of paper, to your affiliate representative.
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Your Affiliate will forward the information to CPS Grants Management,
for final approval and disbursement.
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