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FI-00529-09 (11/13) Page 1 of 2
IN-STATE SHORT TERM ADVANCE
OUT-OF-STATE RECURRING ADVANCE
SEMA4 EMPLOYEE EXPENSE REPORT
Check if advance was issued for these expenses
FINAL EXPENSE(S) FOR THIS TRIP?
Employee Name
Home Address (Include City and State)
Permanent Work Station (Include City and State)
Agency
1-Way Commute Miles
Job Title
Employee ID
Rcd #
Trip Start Date
Trip End Date
Reason for Travel/Advance (30 Char. Max) [example: XYZ Conference, Dallas, TX]
Barg. Unit
Expense Group ID (Agency Use)
Chart
String(S)
A
Accounting Date
Fund
Fin DeptID
AppropID
SW Cost
Sub Acct
Agncy Cost 1
Agncy Cost 2
PC BU
Project
Activity
Srce Type
Category
Sub-Cat
Distrib
%
B
A. Description:
B. Description:
Date Daily Description
Itinerary
Trip Miles
Total Trip &
Local Miles
Mileage
Rate
Meals
Total Meals
(overnight stay)
Total Meals
(no overnight stay)
taxable
Lodging
Personal
Telephone
Parking Total
Time
Location
B
L
D
Depart
Figure mileage reimbursement below
Arrive
Depart
Arrive
Depart
Arrive
Depart
Arrive
Depart
Arrive
Depart
Arrive
Depart
Arrive
Depart
Arrive
VEHICLE CONTROL #
Total Miles
Total MWI/MWO
Total MEI/MEO
Total LGI/LGO
Total PHI/PHO
Total PKI/PKO
Subtotal (A)
MILEAGE REIMBURSEMENT CALCULATION
OTHER EXPENSES – See reverse for list of Earn Codes.
Enter the rates, miles, and total amounts for the mileage listed above. Get the
IRS rate from your agency business expense contact.
Rate Total Miles Total Mileage Amt.
Date Earn Code Comments Total
1.
Enter rate, miles, and amount being claimed at equal to the IRS rate.
2.
Enter rate, miles, and amount being claimed at less than the IRS rate.
3. Enter rate, miles, and amount being claimed at greater than the IRS rate.
4.
Add the total mileage amounts from lines 1 through 3.
5. Enter IRS mileage rate in place at the time of travel.
6. Subtract line 5 from line 3.
7. Enter total miles from line 3.
Subtotal Other Expenses: (B)
8.
Multiply line 6 by line 7. This is taxable mileage.
(Copy to Box C)
Total
taxable mileage greater than IRS rate to be reimbursed: (C)
MIT or MOT
9.
Subtract line 8 from line 4. If line 8 is zero, enter mileage amount from line 4.
This is non-taxable mileage.
(Copy to Box D)
Total nontaxable mileage less than or equal to IRS rate to be rei
mbursed: (D)
MLI or MLO
If using private vehicle for
out-of-state travel: What is the lowest airfare to the destination?
Total Expenses for this trip must not exceed this amount.
Grand Total (A + B + C + D)
I declare, under penalty of perjury, that this claim is just, correct and that no part of it has been paid or reimbursed by the state of Minnesota or by another party except with respect to
any advance amount paid for this trip. I AUTHORIZE PAYROLL DEDUCTION OF ANY SUCH ADVANCE. I have not accepted personal travel
benefits.
Employee Signature _________________________________________________ Date _____________________Work Phone:
Less Advance issued for this trip:
Total amount to be reimbursed to the employee:
Amount of Advance to be returned by the employee by deduction from paycheck:
Approved: Based on knowledge of necessity for travel and expense and on compliance with all provisions of applicable travel regulations.
Supervisor Signature __________________________________________ Date _______________ Work Phone:
Appointing Authority Designee (Needed for Recurring Advance and Special Expenses)
Signature ____________________________________________________________ Date ________________________