STATEMENT OF OFFICIAL IN-STATE TRAVEL
NAME
DEPARTMENT
PAY FROM
FUND CODE
DATE
APPROVED
(Immediate Supervisor)
APPROVED
(President)
POINTS OF TRAVEL
DATE(S) OF
TRAVEL
FROM
TO
NUMBER
OF MILES
MILEAGE
@
.56/MI.
TOTAL
HOUR DPT.
A.M.
P.M.
HOUR RET.
A.M.
P.M.
TOTAL
Registration Fee
I,0
, hereby certify that the travel and
expenses indicated hereon were accomplished in the performance of official
duties pursuant to travel authority granted therein.
Sworn and Subscribed before me this
NOTARY PUBLIC
day of
, 20
My Commission Expires
Mileage
Per Diem
Total Expense Acct.
PER DIEM
AMOUNT