University Dept. Name:

SAP Document Number:

Claimant Telephone No.:

Circle Type Used:

Claimant E-Mail:

Full Name of Claimant (Employee):

Personnel Number:

Building & Room Number:

Reason For Trip

Campus or Station:

Department Contact:

Telephone No. or E-Mail

List expenses by each day. Refer to the listing of allowable travel expenses on http://travel.unl.edu to determine if a receipt must be

submitted for each expense. Itemize all miscellaneous expenses. Be sure to enter departure and arrival times for first and last days.

List times for

first & last day

Dep.

Dep.

Dep.

Dep.

Dep.

Dep.

Dep.

Dep.

I claim reimbursement from the State of Nebraska for the above expenses incurred by me in the line of duty and declare that the above statement of them is a true account of such

expenses for which payment has not been made heretofore by the State of Nebraska.

Print or Type Name of Claimant Date

Print or Type Name of Supervisor or Approving Offical Date

Signature of Claimant*

Signature of Supervisor or Approving Offical*

*Must be an original signature. No copies, faxes or stamps are permitted.

Cost Object

Reimbursement Amount $___________

NOTE AREA