Travel Expense Claim
STATE OF CALIFORNIA
TRAVEL EXPENSE CLAIM
STD. 262 (5/78)
See Instructions and *Privacy Statement on Reverse Side
| Field | Field | Field |
|---|---|---|
| Claimant's Name | SSAN OR EMPLOYEE NUMBER* | DEPARTMENT |
| POSITION | DIVISION OR BUREAU | |
| RESIDENCE ADDRESS* | HEADQUARTERS ADDRESS | TELEPHONE NUMBER |
| CITY STATE ZIP CODE |
CITY STATE ZIP CODE |
|
| (1)MONTH/YEAR | (2) Date | (2) Time | (3) LOCATION WHERE EXPENSES WERE INCURRED | (4) LODGING | (5) MEALS BREAK-FAST | (5) MEALS LUNCH | (5) MEALS O.T., L/T N/C, RELO OR DINNER | (6) INCIDEN-TALS | TRANSPORTATION (A) COST OF TRANS. | TRANSPORTATION (B) TYPE USED | TRANSPORTATION (D) CARFARE, TOLLS, PARKING | TRANSPORTATION (E) PRIVATE CAR USE MILES | TRANSPORTATION (E) PRIVATE CAR USE AMOUNT | BUSINESS EXPENSE | TOTAL EXPENSES FOR DAY |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| SUBTOTALS | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 | |||
| Amount | Account | Fund | Department | Program | Class | Project |
|---|---|---|---|---|---|---|
| 0.00 |
CLAIM TOTAL
Claim details and authorization
(12) NORMAL WORK HOURS
(13) PRIVATE VEHICLE LICENSE NUMBER
(14) MILEAGE RATE CLAIMED
0.58
(11) PURPOSE OF TRIP, REMARKS AND DETAILS (Attach receipts/vouchers when required)
AGENCY ACCOUNTING OFFICE USE ONLY
PAID BY REVOLVING FUND
CHECK NUMBER
(15) I HEREBY CERTIFY That the above is a true statement of the travel expenses incurred by me in accordance with DPA rules in the service of the service of the State of California. If a privately owned vehicle was used, and if mileage rates exceed the minimum rate, I certify that the cost of operating the vehicle was equal to or greater than the rate claimed, and that I have met the requirements as prescribed by SAM Sections 0750, 0751, 0752, 0753 and 0754 pertaining to vehicle safety and seat belt usage.
CLAIMANT'S SIGNATURE
DATE
SIGNATURE OF OFFICER APPROVING TRAVEL AND PAYMENT
DATE
(17) SPECIAL EXPENSE AUTHORIZATION - SIGNATURE and TITLE (See item 17 on reverse)
DATE
Travel Expense Claim
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