University of Maryland Libraries
Expense Statement

The following form, although not required, may be used to assist your Divisional Administrative Assistant in preparing the online ELF Expense Statement.

Traveler

Trip #:
 Social Security #:
Traveler Status:
Is this traveler on University of Maryland payroll at time of this reimbursement? Yes No
FRS #:
 Campus:
 Subcode:
Last Name:
 First Name and Middle Initial:
Address - Street/Apt#: Address only required for individuals not on UM payroll
City:
 State:
 Zipcode:
Department:
Contact Name:
(name of person who is best able to answer questions regarding this travel)
 Contact Phone:
(enter 10 digit phone #)
Email of Contact:
(enter full email address including domain)
Trip Purpose:

Itinerary

Departure Date/Time: / / :
Return Date/Time:       / / :
Origin Airport Code:
 If Airport Code not known, enter City, State & Airport name:
Destination Airport Code:
 If Airport Code not known, enter City, State & Airport name:
Privately Owned Vehicle (POV) Mileage Detail
Date From To POV Miles POV Rate

Expenses

Date      Description               Cost Code FRS         Subcode Working
Fund		 Amount     
Mileage 07
Mileage 07
Total Expenses:  
Working Fund Advance Amount:  
(Do NOT enter Travel Card ATM Advances here).  
Reimbursement Amount:  
Amount to Re-pay University:  

Attestation & Comments

Traveler Attestation
  I certify that I am the "traveler" for the trip listed on this document and that the expenses claimed are in full compliance with university and USM travel policies and with any sponsored program restrictions and will not be/have not been otherwise reimbursed. I further certify that I have provided original receipts, as required, to be retained in the department file.
Signature:
Reviewer Attestation
 As "reviewer" of this form, I certify the following:

  • If the traveler has not made the electronic attestation above, the traveler has provided me with a signed hard copy of this Expense Reimbursement form.
  • The traveler has provided me with original receipts, as required, which agree with the expense submitted for reimbursement.
  • All expenses claimed are in full compliance with university and USM travel policies and with any sponsored program restrictions, and have not been otherwise reimbursed.
    • Comments: