Languages, Literatures, & Cultures Department
TRAVEL REIMBURSEMENT REQUEST FORM (Effective 12/1/2015)
Complete this form. Attach all original receipts. If receipts are smaller than 8½ x 11, tape (do not staple)
them to an 8½ x 11 sheet of paper.
You should make a copy of all documents for your records.
Date:
Rec’d
Name of Traveler:
EmplID
Destination (City
&State or Country:
Departure Date & Time
(Both Required):
Return Date & Time
(Both Required):
Purpose of Trip:
Amount
Pay to
UMass CitiCard?
Description
1. Registration Fee:
2. Airfare:
3. Ground Transport:
4. Lodging/Hotel:
5. Per Diem *:
# of Days:
6. Mileage *:
Total Miles:
Rate*:
See “Travel Expense Reimbursement Guidelines”.
Current rate $0.54 (1/1/16); round up/down actual mileage
- no decimal places.
7. Other (Itemize):
Total:
* Attach a print out of the webpage supporting this information.
Funding source (name
of award, grant, etc.)
1