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<br />STATE OF COLORADO <br />TRAVEL EXPENSE <br /> <br />DEPARTMENT <br />Department of Human Services (IHA) <br /> <br />DIVISION OR AGENCY <br />ITS - CBMS Project <br /> <br />MONTH <br /> <br />YEAR <br />2004 <br /> <br /> TRAVEL MILEAGE MEALS AND LODGING <br />Date Time Time No. Rate Total <br /> FROM TO Depart Return Miles Per Total Bkst. Lunch Dinner Lodg. Total Reimbursable <br /> Mile Items <br /> 0.28 0.00 0.00 0.00 <br /> 0.28 0.00 0.00 0.00 <br /> 0.28 0.00 0.00 0.00 <br /> 0.28 0.00 0.00 0.00 <br /> 0.28 0.00 0.00 0.00 <br /> 0.28 0.00 0.00 0.00 <br /> 0.28 0.00 0.00 0.00 <br /> 0.28 0.00 0.00 0.00 <br /> 0.28 0.00 0.00 0.00 <br /> 0.28 0.00 0.00 0.00 <br /> 0.28 0.00 0.00 0.00 <br /> 0.28 0.00 0.00 0.00 <br />TOTALS 0 0.00 0.00 0.00 0.00 0.00 0.00 0.00 <br />MISCELLANEOUS EXPENSE: <br />(See page two for additional space)1 0.00 <br />PURPOSE OF TRIP: LESS TRAVEL ADVANCE <br /> TOTAL 0.00 <br />PERSONS AND AGENCIES CONTACTED: <br /> <br />"I certify that the statements in the above schedule are true and just in all respects: that payment of the amounts claimed herein has not and will not <br />be reimbursed to me from any other source; that travel performed for which reimbursement is claimed was performed by me on State business <br />and that no claims are included for expenses of a personal or political nature or for any other expenses not authorized by the Fiscal Rules; and <br />that I actually incurred or paid the operating expenses of the motor vehicle for which reimbursement is claimed on a mileage basis. The signatures <br />on this form constitute approval for use of private auto within the Metro area or a 65-mile radius of the office and that the conditions of the <br />use at private auto have been met and adhered to." <br /> <br />PAYEE SIGNATURE DATE ISOCIAL SECURITY NUMBER <br /> MAIL ADDRESS <br />PAYEE PRINT <br /> <br />Reimbursement will by paid State warrant if not checked. <br /> <br /> <br />FISCAL OFFICER SUPERVISOR APPROVING AUTHORITY <br /> Annie Mabry, 720-570-5206 <br /> <br /> I-UNU IU UKG AI-'I-'K UtsJ -::5Uts ts/::5 GtsL KI-'IG J-\IVIUUI~ <br />CBMS 100 IHA 2452 118 9510 61P9 <br />Shaded areas to be completed by the District Accounting Office TOTAL 0.00 <br />TRVLEFT.XLS (Revised 2/01) Questions?? Call Paul Van Riesemann 720-570-5217 <br /> <br />INSTRUCTIONS FOR ELECTRONIC FUND TRANSFER <br />