Attachment V - Travel Request Form.pdf

TRAVEL REQUEST FORM

Notes:

*Per Diem: (1) Traveler reimbursement for per diem (lodging and meals & incidental expenses (M&IE)) is based on the location of the work activity and not the lodging accommodations, unless lodging is not available at the work activity, then the COR & KO/KS may authorize the rate where lodging is obtained. (2) The first and last day of official travel is calculated at 75% of the M&IE total for the work location.

Local Travel: DO NOT USE THIS FORM FOR LOCAL TRAVEL - DHS defines local travel as travel within the local commuting area. Per diem (lodging and meals and incidental expenses) is not authorized and will not be reimbursable for contractor personnel who’s primary worksite (or their home if they do not have a primary worksite) is within 50 miles (one way) of the government installation where work is being performed. Contractor personnel may obtain authorization (via the Local Travel Request Form) for reimbursement for travel costs that exceed their normal commuting costs.

Revised 9 JAN 2015

CONTRACT/ORDER#:

Traveler’s Name: ________________________________________________ Position: __________________________

Purpose of Travel (to include various local locations within trip):

First Day of Travel*: _______________________________ Last Day of Travel*: ______________________________

Departure Location (e.g. residence):_____________________________________________________________________

(City State) Destination/Work Location(s)*: ________________________________________________________________________ (Address/City/State/ZIP Code)

Authorized GSA Lodging Rate & Locality*: _____________________________________________________________

Authorized GSA M&IE Rate & Locality*: _______________________________________________________________

Justification for Lodging Actuals (non-GSA) or Lodging in a Different Locality than the Work Location:

Primary Mode(s) Commercial Air Commercial Rail Commercial Bus Other: ___________________ of Transportation: Rental Car and Fuel (*If authorized, reimbursement includes parking/ferry/bridge/road/tunnel fees or tolls)

POV (*If authorized, reimbursement is limited to GSA mileage and parking/ferry/bridge/road/tunnel fees or tolls)

Will traveler remain in a travel status OR Will traveler return home (or back to their official station) over the weekend? Yes** No over the weekend? Yes** No

**If yes, provide justification (must be the most cost effective option for the government):

Anticipated Misc. Costs: Taxi/Subway Excess Baggage Other: ________________________________

Use of POV to/from Common Carrier Terminal (e.g., airport) instead of Taxi (*The total mileage reimbursement and transportation related expenses (parking fees/ferry/bridge/road/tunnel fees or tolls) together may not exceed the constructive cost for use of a taxi to or from the terminal. Includes drop off at a terminal by a family member or friend.)

Other relevant information: ___________________________________________________________________

TOTAL ESTIMATED TRAVEL COSTS: $___________________________

(This is only an estimated cost; only allowable travel costs will be reimbursed to the Contractor.)

The above travel request is approved. (Both approvals below are required prior to travel.)

COR SIGNATURE DATE

CONTRACTING OFFICER (KO)/CONTRACT SPECIALIST SIGNATURE DATE