TRAVEL SUBSTANTIATION FORM

Name of Traveler *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Purpose of Travel *

Destination *

Date Travel Began *

Date Travel Ended *

Did you receive Per diem PRIOR to travel? *

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.

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

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.

Name