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APTA HOME HEALTH
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140B Purcellville Gateway Drive, Suite 120, Purcellville, VA 20132
Suite 120
Purcellville, VA 20132
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TRAVEL EXPENSE REIMBURSEMENT REQUEST
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 NAME (PRINT):
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 STREET ADDRESS:
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 CITY/STATE/ZIP:
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 TRAVEL PURPOSE:
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 From:To:To:
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See Guidelines for reimbursement limits; original receipts must be attached.
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TRAVEL EXPENSES
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DATE
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 CAR MILEAGE ( INSERT MILES)
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IRS RATE PER MILE (0.725):
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Airfare
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registration
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parking
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breakfast
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lunch
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dinner
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dine and dash coverage
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hotel
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lft from airport to hotel
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uber to airport from hotel
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Miscellaneous
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 $ -
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**MISCELLANEOUS EXPENSE RECORD EXPLANATION
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DATENAME OF GUEST (S)PURPOSELOCATIONAMOUNT
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èTraveler: - I certify this statement is true:
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èEXECUTIVE DIRECTOR APPROVED:
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FOR STAFF USE ONLYTravelPer DiemHonorariumOther
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 PROGRAM/PROJECT #
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 ACTIVITY #
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 LINE ITEM
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FOR ACCOUNTING USE ONLY
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CHARGE TO:DATE PAID:
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CHECK NO:
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CHECK PROCESSOR:
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DOC #:
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DESCRIPTION:
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FINANCE APPROVAL:
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