WOLFS-104 Travel Expense Voucher 6.10.21

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4	Revised 10/01/09						STATE OF WYOMING																																	AGENCY OPTIONAL USE
5							WOLFS-104 TRAVEL EXPENSE VOUCHER																																	Approval #1
6																																					Approval #2
7			DOCUMENT ID:																																		Approval #3
8						DEPT.			DOCUMENT NO.			BFY				MM	DD				YY		CLAIMANT STATUS:
9		GAX											DATE:											State Employee								Legislator or Brd/Comm Member paid as a Leg.											Other
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11																								Contract Employee								Brd/Comm Member paid as a State Employee
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13			CLAIMANT INFORMATION
14			Claimant Number:							VC																			REASON FOR TRAVEL: Give specific reason for travel
15			Invoice Number:																										REASON FOR TRAVEL: Give specific reason for travel
16			Name:
17			Address (street/box):
18			City:											State								ZIP
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20																		MODE OF TRAVEL - Check appropriate box(es).
21					Actual Expense Continuation Sheet, WOLFS-104B attached														State Plane													State Vehicle						Other - Describe:
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23																			Commercial Plane													Personal Vehicle (PV)
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25			TRAVEL SUMMARY
26			Date					Travel From City/Place			Travel To City/Place				Legis Daily Reimb. Rate					Actual Lodging Expense				Federal Lodging Reimb. Rate				Federal M&IE Reimb. Rate			Deductible Meals						Claimant M&IE				Mileage					Total
27			Date					Travel From City/Place			Travel To City/Place				Legis Daily Reimb. Rate					Actual Lodging Expense				Federal Lodging Reimb. Rate				Federal M&IE Reimb. Rate			Bkfast			Lunch	Dinner		Claimant M&IE				Miles	Rate Per Mile		Amount		Total
28																																					-							-		-
29																																					-							-		-
30																																					-							-		-
31																																					-							-		-
32																																					-							-		-
33																																					-							-		-
34																																					-							-		-
35											TOTALS				$ -					$ -																	$ -							$ -		$ -
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37			OTHER REIMBURSABLE EXPENSES																											TRANSPORTATION EXPENSES (OTHER THAN MILEAGE)
38			Date					Description																	Amount				Date				Description													Amount
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45			Total Listed Reimb. Expenses (Including Continuation Sheet)																						$ -					Total Listed Transportation Expenses (Other Than Mileage)																$ -
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47			REMARKS																																				FORMS TOTALS
48																																							Total WOLFS-104						$ -
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51																																							Total WOLFS 104b						$ -
52				CLAIMANT CERTIFICATION - REQUIRED
53				I certify the following by my signature below, under penalty of false swearing pursuant to W.S.6-5-303:
54				1. This voucher is for travel on official business of the State, and is true and accurate.																																			TOTAL CLAIM						$ -
55				2. Each claimed expense is allowable to me under W.S. 9-3-102 or 9-3-103, executive orders and direction, agency policy, and SAO Travel Instruction.																																			TOTAL CLAIM						$ -
56																																							Total WOLFS-112						$ -
57				3. I have complied with required procedures for approval of the travel and reimbursement of the submitted expenses.																																			Total WOLFS-112						$ -
58				4. The State of Wyoming has not paid or incurred any of the expenses claimed in this voucher.																																			Out of Balance Condition						$ -
59																																							Out of Balance Condition						$ -
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61				Claimant Signature (in ink)																						Date										AGENCY INTERMEDIARY APPROVAL - OPTIONAL
62																																				I have read W. S. 9-3-102 and 9-3-103, the current Travel Instructions and Forms provided by the State Auditor's Office, applicable Executive Orders or memoranda, and any applicable agency travel policy. This voucher appears to comply with all applicable reqiuirements for payment.
63				VOUCHER PAYMENT AGENCY HEAD/DESIGNEE APPROVAL - REQUIRED
64				This voucher is approved for payment. W.S. 9-3-102(a)(ii) states, "The head of the agency to be charged for the expenses, or his designee, shall approve the claim for payment. State officers or employees shall not approve their own claims. The head of the agency is responsible to determine the veracity of each claim[.]"
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69				Agency Head/Designee																							Date									Agency Fiscal Approver											Date
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