.
Statens fellesblankett
Surname and
forename
National identity
no (11 digits)
City
Postal code
Home
address
Name/Code of bank
(write on reverse side)
Position
Agency/
Institution
Tax
municipality
Employee no.
(4 or 5 digits)
Claim in
connection with
Bank acct.
Girobank
Dept./
Divisjon
Municipality code
Tax
per cent
Amounts
claimed
SDCode
Total expenses
from reverse side
Overn.
stay
Incident.
expenses
619
614
1084
614
1085
614
1042
614
1042
610
1086
610
1087
Foreign
610
1052
Overnight
accommodation
supplement
No
vouchers
Foreign
610
1052
GTAS*
(domestic)
610
1053
610
1078
610
1056
8-12
hours
More than
12 hours
Overnight hotel
accom. domestic
GTAS*
(foreign)
Private car:
0-9,000 km
Use of own Private car:
transport- more than 9.000 km
ation.
Home - work
Please
(taxable portion)
specify
journey on Private car:
Passenger suppl.
reverse
Other
side
Stay
exeeding
28 nights
Other
expences
NOK
Amount
øre
NOK
(See reverse side) Board
house
Hotel
Other
Virksomhetsregnskap
øre
Kontering
Kode 2
Kode 3
Kode 4
1041
1083
6-12
hours
More than
12 hours
Number
Time
1057
614
9-12
hours
More than
12 hours
Rate
M
Date
1041
Under 5
hours
5-9 hours
Code
Time
Return
Official journey
TT-
Tj.stedsnummer
Date
Departure
Other
Other
Subsistence
allowance, with
overnight
stay
R/N
Vedleggsnr.
Destination and purpose of journey
Course
Please specify
Subsistence
allowance, no
overnight
stay
Brukernummer
Travel and subsistence claim form
1)
2)
111
1069
714
1045
614
1049 1
÷
610
1050 1
÷
Subsistence
allowance
Overnight
accommodation
allowance
Other
Sub-total
Deductions
Breakfast/
lunch/dinner
Breakfast/
lunch/dinner
GRAND TOTAL
Less
advance
received
NET
TOTAL
Claimant’s
signature
Payment
Paid by
8020
Claimed
Date
(Specification on
reverse side)
Reise nr.
÷
Due to
inst.
I, the undersigned, agree that any amount due may be deducted from my salary.
Paid by
(institution)
Date
Approval
(sign. of
authorizing
officer)
Utbetales og posteres i samsvar med foranstående
Payment authorization
Receipt for
Sum received
Date
Signature
payment made
in cash
* GTAS = Government Travel
X-0095 E (Godkj. 08-2005) Elektronisk utgave
Allowance scale for domestic
and foreign travel
Countersignature
Utbetalingsstedets merkn. ved utbetalingen
For regnskapsføreren: 1) Kode SD 712/TT 1047 2) Kode SD 152 / TT 1054
Name
National identity
Journey specification
Expenses
FROM
Date
Time
Mode of transport*
To
Place
Place
Time
Type
Total km
priv. transp.
Currency
Code
Amount
Total km this jorney. Carry forward to Use
of own transportation on front page.
Authoriza- Date
tion for
use of
private car Authorizing officer
+ Total mileage this year (km)
Exhange rate
Sub-total
Mark with X
if transferring km.
Cumulative mileage this year(km)
*For use of private car, please include:
Itinerary - distance driven for each journey, listed by destination and speedometer reading
-reason for detours - local mileage at destination.
Calculating subsistence
allowance
Travel period in connection
with a course ends when the
course starts. New travel period
is initiated at the time course
concludes.
Expenses for accommodation, food, etc.
Currency
Date
Specification
If subsistence allowance is to
be calculated on the basis of
days exceeding 6 hours, the
number of days should be
entered on the reverse side
under «Subsistence/allowance
with overnight stay», TT code
1086/1087/1052
Subsistence and
accommodation by voucher
Enter here food and
accommodation expenses
documented by vouchers. If in
addition to recovering these
expenses you are entitled to a
course allowance, enter the
number of days under TT code
1057 on the front. The total
course allowance should be
entered in the “amount” column.
Total (enter on reverse side, TT-kode 1041)
Overnight stay
Name and address of hotel, boarding
house, etc. (not private lodgings)
Remarks
Code
Amount
Exhange
rate
Amount