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About Us
Board of Directors
Committees
Our History
Meetings
State Council Meetings
Other Meetings
Education
Illinois ENA Education
ENPC / TNCC / CATN / GENE Courses
Conference / Symposia / Seminars
Online Education
CEN/CPEN/TCRN Reviews
BCEN Certifications
National ENA Education
Awards
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Contact Congress
Write Your Legislators
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Online Forms
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TRAVEL SUBSTANTIATION FORM
TRAVEL SUBSTANTIATION FORM
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Name of Traveler
*
First
Last
Address
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
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Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
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Mississippi
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Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
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Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Purpose of Travel
*
Destination
*
Date Travel Began
*
Date Travel Ended
*
Did you receive Per diem PRIOR to travel?
*
No
Yes
Actual Expenses
Meals Day 1
Transport Day 1
Transportation does not include airfare or actual mileage to destination.
Incidentals Day 1
Total Day 1
Meals Day 2
Transport Day 2
Incidentals Day 2
Total Day 2
Meals Day 3
Transport Day 3
Incidentals Day 3
Total Day 3
Meals Day 4
Transport Day 4
Incidentals Day 4
Total Day 4
Meals Day 5
Transport Day 5
Incidentals Day 5
Total Day 5
Meals Day 6
Transport Day 6
Incidentals Day 6
Total Day 6
Meals Day 7
Transport Day 7
Incidentals Day 7
Total Day 7
Prepaid Per-Diem Expenses
Use only if you received Per diem PRIOR to travel.
Received Day 1
Excess Day 1
Excess funds to be returned to the IENA
Received Day 2
Excess Day 2
Received Day 3
Excess Day 3
Received Day 4
Excess Day 4
Received Day 5
Excess Day 5
Received Day 6
Excess Day 6
Received Day 7
Excess Day 7
Total Excess to be Returned
Acknowledgement and Signing
Receipts for any covered expenditure up to the current GSA rate are not required. This form must be completed, signed, and returned to Illinois ENA within 30 days of the travel end date. Any reimbursement requests received more than 30 days after the end of the calendar year cannot be honored.
The current GSA rate is available
HERE
.
Signature
Clear Signature
Use your mouse to sign the form, this constitutes an electronic signature and that you attest to the truthfulness and accuracy of this completed document.
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