JUDICIAL BRANCH EXPENSE ACCOUNT FORM
For Travel Taken after XXXXX, XX, XXXX
(Please refer to Instructions)
(1)
(2)
(3)
(4)
(5)
(6)
Department
Unit or Division
Social Security Number (last 4 digits only)
GEARS Vendor Number (if known)
(9) Mileage Reimbursement Rate (cents per mile) =
(10) Total Commute Miles (round trip to office) =
Employee/Payee Name
Work Phone #
(7) Assigned Office Location (Town/City)
(8) Full Home Address
(11) Are you a Recalled / Senior Judge? (Yes or No)
(12) Are you a Judicial Branch employee? (Yes or No)
Date of Travel
Day of Travel
(13)
(14) Overnight LodgingsHotel Room*
Total
Check box
Standard Daily Meal Allowance#
(15)
Airfare, Taxi, Shuttle, etc.*
Rental Car *
Bus or Metro
Bridge, Tunnel or Road Toll
Mileage
Parking*
Miscellaneous Expenses*
Total Reimbursement
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
* Receipts required, except as noted in the Travel Policy.
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
# Reduce the Daily Allowance by the Standard Meal Allowance for each meal that was provided to you. If meal reimbursement is requested for an event not held at
the JECC, attach a copy of the agenda as provided.
(16) Purpose of Travel :
Date of Travel
Day of Travel
Travel Status
Start
End
TERRITORY COVERED INCURRING ABOVE EXPENSES
(17)
(18)
(21)
If mailing is required by payee, please return form to:
(24)
(22)
Total Miles Less
Traveled(19) Commute(20)
Reimbursed
Miles
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
Date:
Signature of Employee / Payee
[As the requestor, you are certifying that the information is
accurate and that payment has not been received.]
Provide address for your office location
(23)
Date:
Approved by Immediate Supervisor or Authorized Judiciary Approver
Work Phone
[As the approver, you are certifying that all of the information
is correct.]