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Traveler Title Department Prepared By / Phone Number Date Submitted
         
Bear Number TR  Number Departure Date/Time Return Date/Time Destination
         
Address   Total FOAPAL Number(s) to be charged     Optional  
  Due Traveler * Index Fund Orgn Acct Prog Actv Amount
  0.00              
               
                 
Mileage   (A)           Meals   (B)     Lodging   (C)
    Date From To Miles Rate Total Date Bkst. Lunch Dinner Total Date Rate
        0.28 0.00         0.00    
        0.28 0.00         0.00    
        0.28 0.00         0.00    
        0.28 0.00         0.00    
        0.28 0.00         0.00    
        0.28 0.00         0.00    
        0.28 0.00         0.00    
        0.28 0.00         0.00    
      TOTAL (A)   0.00       TOTAL (B) 0.00 TOTAL (C) 0.00
Other Expenses (D)     University Paid Expenses (E)       TOTALS      
Date Item Amount Airfare      Total Mileage (A) 0.00
      Lodging      Total Meals (B) 0.00
      Registration      Total Lodging (C) 0.00
      Other (List)      Total Other (D) 0.00
                Grand Total 0.00
               Less Univ. Advance (If Any)  
               Less Traveler Obligation  
  TOTAL (D)   0.00       0.00  Amount Due Traveler 0.00
 Amount Due University 0.00
I certify that the statements in the above schedule are true and just in all respects; that payment of the              
amounts claimed herein has not and will not be reimbursed to me from  any other sources; that travel    SUPPLEMENTARY INFORMATION
performed for which  reimbursement is claimed was performed by me on State business and that no      
claims are included for expenses of a personal or political nature or for any other expenses not authorized     
by the Fiscal Rules; and that I actually incurred or paid the operating expenses of the motor vehicle for    
which reimbursement is claimed on a mileage basis.   * If an index number is used, FOAPAL #'s are not filled in.
TRAVELER'S SIGNATURE                                       DATE   SUPERVISOR'S  SIGNATURE                  DATE AUTHORIZED SIGNATURE                        DATE
      GRANTS/CONTRACTS SIGNATURE           DATE
VP SIGNATURE DATE (IF APPLICABLE)