National Advisory Mental Health Council

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Domestic Travel Voucher Expenses

Note: This form is intended for use by the NIMH National Advisory Mental Health Council Members only.

Fill-in the form below. Print a copy of the completed form for your records. Press the [Email] button at the bottom of the form (this will transmit a copy of the report to Ms. Dabney). Please be advised that completion of the form does not negate the need to mail your receipts. All receipts related to the travel claim must be submitted to Ms. Dabney in order to obtain reimbursement.

Upon pressing the [Email] button, you will be linked to a Travel Receipt Transmission Form. Print the Travel Receipt Transmission Form and mail it, along with your receipts, to the address listed on the form.


Trip & Traveler ID

Travel Order Number: Traveler Name: Revision

Trip Duration

The government per diem rate for meals and incidental expenses for Washington, DC is $50.00 per 24 hour period which is calculated using your departure and return dates and times. The cost of any arranged meals (working meal) will be deducted from your per diem.
Depart Date Depart Time
Return Date Return Time

Main Expenses

Amount
Out of Pocket Commercial Air/Train fare (submit unused portion of ticket and passenger receipt).
Lodging (reimbursable lodging expenses limited to: per night room rate, room occupancy tax, State sales tax, and phone charges of up to $5 per day).
Registration Fee

Business Services

Submit receipts for business service expenditures (copying, faxing, etc.), as well as business phone calls not listed on the lodging statement.
Amount Description

Privately Owned Transportation (POV)

Reimbursement is based on cents per mile: automobile 36.0 cents, motorcycle 27.5 cents, and aircraft 95.5 cents.
Mileage To:
Mileage Back: 		Automobile Motorcycle Aircraft
Mileage To:
Mileage Back: 		Automobile Motorcycle Aircraft

Transportation Parking

Short-Term Cost:
Long-Term Cost: from thru

Ground Transportation

(Receipt(s) must be provided for ground transportation expenses above $75.00)
Date Category Location Cost
Location From:
To:		 Cost:
Location From:
To:		 Cost
Location From:
To:		 Cost:
Location From:
To:		 Cost:
Location From:
To:		 Cost:
Remarks:
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Document last updated on 1/23/03