Employee Expense Report Form
Employee Expense Report Form
Employee Expense Report Form
Important
• Complete your totals and attach documentation (including Out-of-State/International Travel Authorization)
• Obtain appropriate signatures and submit to Business Services (Owens 106) or [email protected]
• Please allow 3 weeks for processing
• If submitted 60 days after expense, the reimbursement becomes taxable and tax withholding must be taken
• For an advance settlement, Employee Expense Reports must be submitted within 5 days after travel
• Visit Business Services’ Travel and Business Expenses webpage for additional policies and procedures
Minnesota State University Moorhead is an equal opportunity educator and employer and is a member of the
Minnesota State Colleges and Universities System. This information will be made available in alternate format upon
request by contacting Disability Services at 218.477.4318 (VOICE) or 1.800.627.3529 (MRS/TTY)
Employee Expense Report
Section I: Travel Type: □In-State □Out-of-State/International (must attach travel authorization) Report Type: □Reimbursement □Advance □Settlement
Name: Travel Destination and Purpose of Expense:
Home Address:
Work Address:
Work Phone: Employee ID# Bargaining Unit: Required
Department/Office: Dragon ID # (Select)
Section II: Do not include expenses incurred on University Purchasing card or PO. Only include expenses for which reimbursement is being requested.
Daily Itinerary Daily Mileage Mileage Meal Amount
Reason for Travel Lodging Amount Daily Total
Date Time Location Mileage Rate Amount B L D
Departure
Arrival 0.00 0.00
Departure
Arrival 0.00 0.00
Departure
Arrival 0.00 0.00
Departure
Arrival 0.00 0.00
Departure
Arrival 0.00 0.00
Departure
Arrival 0.00 0.00
Section II Subtotals: 0.00 0.00 0.00 0.00 0.00 0.00
I declare under the penalties of perjury that this claim is just and correct and that no part Section III:
of it has been paid except with respect to those advance amounts herein shown and hereby Date Other Expenses Total
authorize payroll deduction of any such advances not accounted for within 28 days after
completion of trip. I have not claimed frequent flyer mileage or other travel benefits as my own.
______________________________________________________________________________
Employee’s Signature Date
Section III Subtotal: 0.00
I approve based on my knowledge of the necessity for the expense and on the basis of TOTAL OF SECTION II AND III: 0.00
compliance with all provisions of applicable policy and procedure. Less Advance (If Applicable):
TOTAL AMOUNT TO BE PAID TO EMPLOYEE:
______________________________________________________________________________
Section IV: Total amount must equal amount to be paid to employee:
Supervisor/Department Chair’s Signature Date
Cost Center number/name_______________________________________ $_____________
______________________________________________________________________________ Cost Center number/name_______________________________________ $_____________
VP/ Dean/Director’s Signature Date
Cost Center number/name_______________________________________ $_____________
Rev. 1/2020