DOT - RTAP TRAVEL EXPENSE VOUCHER

RTAP TRAVEL EXPENSE VOUCHER
North Dakota Department of Transporation, Local Government
SFN 58369 (03/15)
North Dakota Department of Transportation, Local Government*

In-StateOut-of-State
REQUEST FOR REIMBURSEMENT (This RTAP TRAVEL EXPENSE VOUCHER must be submitted within 6 weeks of the event or June 15, whichever is earlier. Use a separate form for each individual for each trip. Documentation must be provided if airfare costs in excess of the basic least expensive unrestricted accommodations offered. NDDOT only reimburses for allowable costs based on 2 CFR Part 200.474. Upon submittal the form(s) and attachements will be sent to the Transit Section for approval.
Event and Location*
Date From*

MonthDayYear
Date
Date To*

MonthDayYear
Date
Transit Agency Name*
Individual's Name*
Work Telephone Number*
Mileage Reimbursement

Personal Vehicle ($0.70 per mile)Project Vehicle ($0.21 per mile)
Beginning Odometer Reading
Ending Odometer Reading
Total Miles
X Mileage Rate
Total Mileage Cost

Out-of-State Only - based on GSA Per Diem Rates
Departure Date

MonthDayYear
Date
Departure Time
Return Date

MonthDayYear
Date
Return Time
Note: When entering out of state meals, enter the first and last days reduced by 75% of the total for those days.
75% of First and Last Travel Days Amount
Number of Days (First and Last)
Breakfast Cost
Number of Breakfasts
Breakfast Total
Lunch Cost
Number of Lunches
Lunch Total
Dinner Cost
Number of Dinners
Dinner Total
Total Meals

Commercial Transportation (receipts must be attached)
Airfare
Vehicle / Shuttle
Other (Specify)
Other Cost
Total Commercial Transportation
Lodging Reimbursement (receipts must be attached)

IN STATE: Lodging may not exceed $99 plus tax, per night If not available, select the next cheapest rate and provide a description on the receipt.
OUT OF STATE: Actual lodging expense only with prior approval.
Total Lodging
Registration Fee (receipts must be attached)
Total Amount of Claim Requested
Upload Reciepts (pdf, jpg/jpeg, png, gif, doc or docx) - 8MB maximum size

Cancelof
I hereby certify that items claimed are accurately stated and I also acknowledge that any willful certification of an unlawful expense constitutes a misdemeanor as provided by state law NDCC 44-08-03.
Signature*
Date*

MonthDayYear
Date
OOS First/Last Total
Should be Empty: