1-17-8: REIMBURSEMENT FORM:

The following form will be used in conjunction with requesting travel and expense approval and reimbursement. Reports should be accompanied by receipts for all individual expenses.

      VILLAGE OF WAYNE TRAVEL AUTHORIZATION

      AND EXPENSE REIMBURSEMENT FORM

I.   GENERAL INFORMATION

Name:                                     Title:          

Signature:                                     (Note: your signature serves as verification of the information set forth herein)

Purpose of Travel or Expense Incurred:

Destination/Venue in Which Expense Was Incurred:

II.   EXPENSES:

   A. For Travel

   Number of Days:        Departure Date:        Return Date:    

   Public Transportation (Ground Travel)/Taxi:      

   Mileage:       

   Hotel/Lodging:       

   Conference Fees:       

   Meals:      

   B. Miscellaneous Reimbursements:

   Sustenance:       

Incidentals (e.g. telephone calls, fax, copying for Village business):       

III.   Total Reimbursement Sought:    

Approval:                                     Date:          

(Ord. 16-17, 12-20-2016)