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Per Diem Form- In-State Travel

Please complete the form below. Required fields marked with an asterisk *

Form #2

PER DIEM REQUEST FOR FEDERAL/GENERAL FUNDS

This form must be turned in by the first Friday of the month of travel in order to receive per diem money prior to depature.

Per Diem for meals is to cover the difference it would have cost to eat out vs. eating at home; not to cover your entire meal.

WCSD #1 cannot reimburse for meals furnished as part of registration/conference/continental breakfast fees.

Conference/Workshop Title:*

Answer Required

For In-State Travel & Surrounding Area (80 mile radius from Newcastle):

Destination:*

Answer Required

Travel Details:

Leaving from Newcastle:

Departure Date*

Answer Required

Departure Time*

Answer Required

Departure Date Meals*

Note: mark lunch and supper if leaving before 11:00 AM, mark supper only if leaving between 11:00 AM and 4:00 PM

Answer Required

Lunch ($9.00)

Supper ($15.00)

Number of days in between leaving and returning:

Enter Number of Days*

Answer Required

Returning to Newcastle:

Return Date*

Answer Required

Return Time*

Answer Required

Return Date Meals*

Note: mark breakfast if returning after 8:00 AM, mark breakfast and lunch if returning after 2:00 PM, and mark lunch and supper if returning after 7:00 PM

Answer Required

Breakfast ($7.00)

Lunch ($9.00)

Supper ($15.00)

Breakfast Subtotal*

[Add all Breakfast meal costs, enter below. Exclude $]

Answer Required

Lunch Subtotal*

[Add all Lunch meal costs, enter below. Exclude $]

Answer Required

Supper Subtotal*

[Add all Supper meal costs, enter below. Exclude $]

Answer Required

Total Per Diem Request*

(be sure to deduct cost of meals provided with registration fees and/or motel) [Enter Total Per Diem Dollar Request, exclude $]

Answer Required

Employee Signature*

[Insert Digital Signature File below]

Answer Required

Choose a file or drag it here.

Today's Date*

Answer Required

Printed Staff Name*

Answer Required

Funding Account Number*

Answer Required