STATE OF OREGON

TRAVEL EXPENSE DETAIL SHEET

Department of Administrative Services
1. Name of Employee

2. Agency

3. Period (Month and Year)

4. Official Station

5. Division, Work Unit, PCA

6. Regular Schedule Work Shift

8am-5pm

7.

Unrepresented

Management Service

Board/Commission
Member

Executive Service

Bargaining Unit Name

Other

to

Volunteer

Other

Home Address:

Employee ID
9.

8.

Date

Time of
Departure

10.

11.

12.

Time of
Arrival

Per
Diem/
Full Day

Description

Individual Meal
Reimbursement
Breakfast Lunch
Dinner
25%
25%
50%

13.

14. Total

Lodging
(Less Tax)

Meals and Lodging

-

15. Totals
16.

(Office Use Only)

PCA

OBJ

Totals

17.

Amount

Date

18.
Miscellaneous Expenses
Fares, Private Mileage, Room Tax, Telephone,
Baggage, Other

19.
20.
21.
22.
23.
Total
PVM
Commut Reimbursed Rate per
Amount
Miles
e Miles
PVM Miles
Mile
Travelled

0.0
0.0

0.575
0.575

0.0
0.0
0.0

0.23
0.23
0.56

0.0
0.0

0.56
0.235

0.0

0.235

24. Section Total

25. I did_____ did not _____ accept travel awards as a result of, or associated with this state business trip.
Completion of this block is mandatory. Travel expense reimbursement claims will not be processed if this block is left blank. Travel awards included,
but may not be limited to , airline frequent flyer miles and hotel or car rental frequent customer awards.
26. REASON FOR TRAVEL: (Be specific.)
27. Grand Total Amount
$
28. Travel Advance Amount
29. Amount Due Employee/State

I certify that all reimbursements claimed reflect actual 31. Signature of Employee

30. Received Training

32. Title

Conducted Training

Date

duty required expenses or allowances entitled; that no

part thereof has been heretofore claimed or will be
claimed from any other source.
I certify that the above claimed expenses are authorized
duty required expenses. Funds for payment of this claim
are available in the approved budget for the period
covered and have been allotted for expenditure.

33. Approved By

34. Title
Administrator/Designee if OOS

Date

INSTRUCTIONS

Receipts for all lodging expenses claimed and for miscellaneous expenses over twenty-five dollars must be attached to the origi
copy of this form. A copy of the approved out-of-state travel authorization must be attached when expenses are claimed for out-of-st
travel. Approval and justification for reimbursements over applicable per diems must be attached. The original travel expense de
sheet should be submitted for payment. Employees should retain a copy for their records.

These instructions are intended to answer the questions that most frequently arise in the use of this form. Rules for state busine
travel are published as Chapter 40.10.00.PO of the Oregon Accounting Manual. That document contains references to the relev
Oregon Revised Statutes.
1.

Name of Employee: Enter the name of the employee

claiming reimbursement.

17. Date: Show the month and day(s) in which the miscellaneo
expense(s) is incurred (e.g., 8/5 or 8/5-6).

2.

Agency: Enter the name of the employing agency (i.e.,

Department of Administrative Services).

3.

Period: Enter the month and the year during which the
expenses were incurred. (e.g., July 2001).

4.

Official Station: Enter the official headquarters of the

employee claiming reimbursement.

18. Miscellaneous Expenses: Fares, Private Car Mileage, Ro

Tax, Telephone Charges, and Other. Identify the ex
expense claim. Sample entries are: Private car mileag
Salem to Portland and return. Telephone Portland
Salem. Parking State car, license E999-000. Shuttle
Airport to hotel Chicago. (Use additional forms, if neede

5.

Division, Work Unit, or Cost Center: Enter the organizational

work unit to be charged (e.g., Budget and Management
Division or Cost Center Number).

20. Commute Miles: If travelling from the residence to

temporary work location, enter deduction for commute mi
as applicable.

6.

Regular Scheduled Work Shift: Check the standard 8:00 am

to 5:00 pm work schedule or provide the actual schedule
start and stop times. If the schedule varies from day to day,
attach details to this form.

21. (Calculated Field): This field subtracts out the commute m

if applicable.

Each state officer or employee must indicate if he/she is a

member of Unrepresented, Management Service, Executive
Service, a Board, a Commission, a Volunteer, or a Bargaining
Unit. If a Bargaining Unit Member, indicate the name of the
union which represents the employee. Claimants, who are
not state employees, indicate other with an explanation. If
on a job rotation to another agency, please note under
other.

23. Amount: Enter the amount for each item of expense.

7.

8.

9.

Date: Make a separate line entry for each day of travel in the
month. Enter the date for the day of the month. Use
additional forms as necessary.
Time of Departure: Enter the time of departure. Round to the
nearest hour. When expenses are being claimed, time of
departure is required.

10. Time of Arrival: Enter the time of arrival. Round to the nearest
hour. When expenses are being claimed, time of arrival is
required.
11. Destination: Show the location where the expense was
incurred. If the expense was incurred in transit, enter En
route to (name of destination).
12. Per Diem: Enter the applicable daily meal per diem for the
travel destination. Enter the amount of individual meal
allowance amounts derived from the applicable daily meal
per diem for the travel destination when a partial day of travel
is being claimed. (e.g. first and last day of travel) These
blocks are also used by elected officials or members of
boards and commissions claiming actual and necessary
expenses per DAS travel rules.
13. Lodging: Enter the actual cost of lodging, not including room
tax (see 18 for room tax reimbursement).
14. Total Meals and Lodging: Enter the total of the amounts
shown under Item 11, or under Items 12 and 13 for each day.

19. Enter the total private vehicle miles travelled.

22. Rate Per Mile: Enter rate per mile for private vehicles.

24. Show the total of column 21.

25. Travel Awards: Check the appropriate boxes regarding a

travel awards accepted as a result of this travel. T
completion of this block is mandatory in order to obt
reimbursement for the expenses claimed on this fo
Agencies are mandated to collect this information a
maintain records. Travel awards include, but are not limi
to airline frequent flyer miles, hotel and car rental points.

26. Reason for Travel: Be specific in stating reason for travel a

subsequent expenses incurred (e.g., traveled to Washingt
D.C., to meet with congressional delegates on health c
issues).

27. Grand Total Amount: Add expenses from Total of Meals a

Lodging to Total of Miscellaneous Expenses.

28. Travel Advance Amount: Enter the amount of the tra

advance received for the trip. Enter zero (0) if no advan
was requested. Subtract the Advance Amount from
Grand Total Amount.

29. Amount Due Employee/State: Enter total amount emplo

owes State of Oregon (a personal check/money order ma
payable to State of Oregon) or enter total amount State
Oregon owes employee.

30. Received or Conducted Training: If this travel was related

training received or conducted, check the appropriate box.

31. Signature of Employee: The travel expense detail sheet m

be signed by the employee. (Note the certification tha
made upon signing the form.)

32. Title: Enter the title of the employee claiming reimburseme

15. Show the total of each column at the bottom of the columns.

33. Approved by: Each travel expense detail sheet must

approved by or for the head of the employing agency. (N
the certification that is made upon signing the form.)

16. Cost Distribution: This section is for the use of the fiscal unit

34. Title: Enter the title of the person actually approving