ATTACHMENT A -
Request For Reimbursement of Lodging at Actual Cost
In-State/Out of State
Name of Employee___________________________________________ Date________________________
Destination/Hotel ________________________________________________________________________
Travel Dates_______________________________ Rates to Be Approved__________________________
JUSTIFICATION FOR: (Mark the type of travel and the appropriate justification)
_____________ In-State
_____________ Lodging costs below the caps provided for in MOM 1-0340.20 or 1-0340.25 are
temporarily unavailable due to seasonal demand or to special functions such as fairs,
sporting events or conventions; or
_____________ Emergency travel arrangements preclude being able to find accommodations at costs
below the caps provided for in MOM 1-0340.20 or 1-0340.25; or
_____________ Remote locations with limited accommodations within a 15-mile radius preclude
obtaining accommodations at costs below the caps provided for in MOM 1-0340.20
or 1-0340.25; OR
_____________ There is reasonable cause to believe person safety is at risk due to employment
position; AND
_____________ Reimbursement at actual cost is within the agency's authorized appropriation level.
EXPLANATION:
_____________ Out of State
_____________ Government rates are not available at the hotel; and
_____________ Government or significantly lower rates are not available at another hotel within
a reasonable distance; OR
_____________ It is necessary for purposes of accessibility and/or security to stay at the hotel
in which the conference is being held; OR
_____________ Emergency or last minute travel arrangements preclude finding accommodations
within the federal guidelines; AND
_____________ Reimbursement at actual cost is within the agency's authorized appropriation level.
APPROVED BY: ________________________________________________ DATE__________________
Director or Designated Approving Authority
|
