Fillable Printable Employee Trip Expense Report Template - Minnesota
Fillable Printable Employee Trip Expense Report Template - Minnesota
Employee Trip Expense Report Template - Minnesota
FI-00529-09 (11/13) Page 1 of 2
IN-STATE SHO RT TERM ADVANCE
OUT-OF-STATE RECURRI NG ADV ANCE
SEM A4 EM PLOYEE EXPENSE REPORT
Check if advance w as issued for these expenses
FINAL EXPENSE(S) FOR THIS TRIP?
Employee Name
Home Address (Include City and State)
Permanent Work Station (Include City and State)
Agency
1-Way Commute Mi les
Job Title
Employee ID
Rcd #
Trip Start Date
Trip End Date
Reason for Travel/Advance (30 Char. Max) [example: XYZ Conference, Dallas, TX]
Barg. Unit
Expense Group ID (Agency Use)
Chart
String(S)
A
Accounting Date
Fund
Fin DeptID
AppropID
SW C ost
Sub Acct
Agncy Cost 1
Agncy Cost 2
PC BU
Project
Activity
Srce Type
Category
Sub-Cat
Distrib
%
B
A. Descript i on:
B. Descript i on:
Date Daily Description
Itinerary
Trip Mil es
Total Trip &
Loc al Mil es
Mileage
Rate
Meals
Total Meal s
(overnight stay )
Total Meal s
(no ov erni ght stay)
taxable
Lodging
Personal
Telephone
Parking Total
Time
Location
B
L
D
Depart
Figure mi l eage reimbursement below
Arrive
Depart
Arrive
Depart
Arrive
Depart
Arrive
Depart
Arrive
Depart
Arrive
Depart
Arrive
Depart
Arrive
VEHICLE CONT R OL #
Total Miles
Total MWI/MWO
T otal MEI/MEO
Total LGI /L GO
Total PHI/PHO
Total PKI/P KO
Subtotal (A)
MIL E AGE REIM BURS E MENT CALCULATION
OTHER EXPENSES – See reverse for list of Earn Codes.
Enter the rates, miles, and total amounts for the mileage listed above. Get the
IRS rate from your agency business expense contact.
Rate Total Miles Total Mileage Amt.
Date Earn Code Comments Total
1.
Enter rate, miles, and amount being claimed at equal to the IRS rate.
2.
Enter rate, miles, and amount being claimed at less than the IRS rate.
3. Enter rate, miles, and amount being claimed at greater than the IRS rate.
4.
Add the total mileage amounts from lines 1 through 3.
5. Enter IRS m ileage rate in place at the t im e of travel .
6. Subtract line 5 from line 3.
7. Enter total mi les from line 3.
Subtotal Other Expenses: (B)
8.
Multip ly line 6 by line 7. This is taxable mileage.
(Copy t o Box C)
Total
taxable mileage greater than IRS rate to be reimbursed: (C)
MIT or MOT
9.
Subtract line 8 from line 4. If line 8 is zero, enter mi leage amount from line 4.
This is non-taxable mileage.
(Copy t o B ox D)
Total nontaxable mileage less than or equal to IRS rate to be rei
mbursed: (D)
MLI or MLO
If using private vehicle for
out-of-state travel: What is the lowest airfare to the destination?
Total Expenses for this trip must not exceed this amount.
Grand Total (A + B + C + D)
I declare, under penalty of perjury, that this claim is just, correct and that no part of it has been paid or reimbursed by the state of Minnesota or by another party except with respect to
any advance amount paid for this trip. I AUTHORIZE PAYROLL DEDUCTION OF ANY SUCH ADVANCE. I have not accepted personal travel
benefits.
Employee Signature _________________________________________________ Date _____________________Work Phone:
Less Advance issued for this trip:
Total amount to be reimbursed to the employee:
Amount of Advance to be returned by the employee by deduction from paycheck:
Approved: Based on knowledge of necessity for travel and expense and on compliance with all provisions of appli cable travel regulations.
Supervisor Signature __________________________________________ Date _______________ Work Phone:
Appointing Authority Designee (Needed for Recurring Advance and Special Expenses)
Signature ____________________________________________________________ Date ________________________
FI-00529-09 (11/13) Page 2 of 2
EMPLOYEE EXPENSE REPORT (Instructions)
DO NOT PAY RELOCATION EXPENSES ON THIS FORM.
See form FI-00568 Relocation Expense Report. Relocation expenses must be
sent to Minnesota Management & Budget, Statewide Payroll Services, for pay-
ment.
USE OF FORM: Use the form for the following purposes:
1. To reimburse emp loy ee s for author iz ed travel expenses.
2. To request and pay all travel advances.
3. To request reimbursement for small cash purchases paid for by employees.
Description In State Out of State Description In State Out of State
Advance ADI ADO Membership
Airfare ARI ARO Mileage > IRS Rat e MIT* MOT*
Baggage Handling BGI BGO Mileage < or = IRS Rate MLI MLO
Car Rental CRI CRO Network S ervices
Clothi ng A l l owance Other E xpenses OEI OEO
Clothi ng-Non Cont rac t Parking PKI PKO
Com munications - Other Photocopies CPI CPO
Conference/Registration F ee CFI CFO
Pos t al , Mail & S hi ppi ng
Svcs.(outbound)
Department Head Expense St orage of S tate P ropert y
Fax FXI FXO Supplies/Materials/Parts
Freight & Del i very (inbound) Telephone, B usiness Use BPI BPO
Hosting Telephone, P ersonal Use PHI PHO
Laundry LDI LDO Training/Tuit i on F ee
Lodging LGI LGO Taxi/A i rport Shutt l e TXI TXO
Meals Wit h Lodgi ng MWI MWO Ves t Rei mburs ement
Meals Wit hout Lodgi ng MEI* MEO* Note: * = t axable, taxed at supplemental rat es
SMP
MEM
CLN
VST
NWK
PMS
HST
COM
FDS
TRG
Earn Code
CLA
Earn Code
STO
DHE
COMPLETION OF THE FORM: Employee: Complete, in ink, all parts of this
form. If cl aiming reimbursement, enter actual amounts you paid, not to exceed
the l imits set in your barg aini n g agreement or compensation plan. If you do not
know these limits, contact your agency's business expense contact. Employees
must submit an expense report within 60 days of incurring any expense(s) or the
reimbursement comes taxable.
All of the data you provide on this form is public information, except for your home
address. You are not legally required to provide your home address, but the state of
Minnesot a cannot process certain mileage payments with out it .
Supervisor: Approve the c orrectness and necessity of this request in compliance with existing bargaining agreements or compensation plans and all other applicable rules and poli-
cies. Forward to the agency business expense contact person, who will then process the payments. Note: The expense report f orm mu st include or ig in al signa tures.
Final Expense For This Trip?: Check this box if there will be no further expenses submitted for this trip. By doing this, any outstanding advance balance associated with this trip will
be deduc ted fr om the next payche ck that is issued .
1-Wa y Commute Miles: Enter the number of miles from your home to your permanent workstation.
Expense Group ID: Entered by accounting or payroll office at the time of entering expenses. The Expense Group ID is a unique number that is system-assigned. It will be used to
reference any advance payment or expense reimbursement associated with this trip.
Earn Code: Select an Earn Code from the list that describes the expenses for which you are requesting reimbursement. Be sure to s elect the code that correctly reflects whether the
trip is in state or out-of-state. Note: Some expense reimbursements may be taxable.
Travel Ad vances, Short-Term and Recurring: An employee can only have one outstanding advance at a time. An advance must be settled before another advance can be issued.
Travel Ad vance Settlement: W hen the total expenses submitted are l ess than the advance amount or if the trip is cancelled, the employee will owe money to the state. Except for
rare situations, personal checks will not be accepted for settlement of advanc es; a deduction will be taken from the employee's paycheck.
FMS ChartStrings: Funding source(s) for advance or ex pense(s)
Mileage: Use the Mileage Reimbursement Calculation table to figure your mileage reimbursement. Mileage may be authorized for reimbursement to the employee at one of three
rates (referred to as the equal to, less than, or greater than rate) . The rates ar e specif ied in the appl icable bar g ain ing agr eeme nt /c om pen sati on plan. Note: If the mileage rate you
are using is above the IRS rate at the time of travel (this is not common), part of the mileage reimbursement w ill be taxed.
Vehicle Control #: If your agency assigns vehicle control numbers follow your agency’s internal policy and procedure. Contact your agency’s business expense contact for more
information on the vehicle control number procedure.
Personal Trav el Benefit s: State employ ees and other offi ci als cannot accept personal benefits resulting from travel on state business as their own. These benefits include frequent
flyer miles/poi nts and other benefits (i.e. discounts issued by lodging facilities.) Employees must certify that they have not accepted personal travel benefits when they apply for
travel reimbursement.
Receipts: Attach itemized receipts for all expenses except meals, taxi services, baggage handling, and parking meters, to this reimbursement claim. The Agency Designee may, at
its option, require attachment of meal receipts as well . Credit card receipts, bank drafts, or cancelled checks are not allowable receipts.
Copies and Distribution: Su bmit the orig ina l docu ment for pay ment and reta in a copy for your employee records.
