One-way Travel Expense Reimbursement Form


Contact Information

Name of Fellowship:*
Name:*

Departure Information

Departure date/time:*
:  
Address:*

Arrival Information

Arrival date/time:*
:  
Address:*

Expenses
All travel must follow GSA guidelines. See www.gsa.gov for current maximum lodging and per diem rates and the personally owned vehicle (POV) reimbursement rate. You will not be reimbursed for receipts that exceed these rates unless prior approval has been given.

Airfare

Are you requesting airfare reimbursment?*
$
No File Chosen
File uploads may not work on some mobile devices.

Mileage (POV)

Please check the GSA site for the current mileage reimbursement rates.

Are you requesting POV mileage reimbursement?*
$
$
No File Chosen
File uploads may not work on some mobile devices.

Lodging

Are you requesting lodging reimbursement?*
$
Include taxes.
No File Chosen
File uploads may not work on some mobile devices.

Car Rental
Please note that per the GSA regulations for rental cars, Personal Accident Insurance (PAI), Collision Damage Waiver (CDW), and Theft insurance are NOT reimbursable.

Are you requesting car rental reimbursement?*
$
$
No File Chosen
File uploads may not work on some mobile devices.

Per Diem

Are you requesting per diem reimbursement?*
$
75% of GSA per diem rate for destination
$

Miscellaneous Expenses

Are you requesting reimbursement for miscellaneous expenses?*
(e.g. parking, baggage fees, internet fees, taxi fees)
$
No File Chosen
File uploads may not work on some mobile devices.
No File Chosen
File uploads may not work on some mobile devices.
$
Address to which you'd like your reimbursement sent:*

eSignature

Current date:*
eSignature: /s/*

By typing my name and the current date in the form fields above, I certify that the information provided in this form is complete and accurate. I understand and agree that my eSignature executed in conjunction with the electronic submission of this form will be legally binding and such transaction will be considered authorized by me. The South Carolina Universities Research and Education Foundation (SCUREF), the University of South Carolina Aiken (USCA), and the program sponsors have the right to verify all information contained in this form and make reasonable inquiries should any doubts about this form or it's attachments arise. I understand that my failure to provide complete, accurate, and truthful information on this form will be ground to deny or withdraw my reimbursement. I agree that no certification authority or other third party verification is necessary to validate my electronic signature; and that the lack of such certification or third party verification will not in any way affect the enforceability of my signature or resulting contract between me, SCUREF, USCA, and the program sponsors.

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