Attachment_3-Local_Travel_Request_Form_BB5081.pdf

LOCAL TRAVEL REQUEST FORM

31JULY2014

CONTRACT#: HSCG84-16-D-BB5081

ORDER#:

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 residence, if they do not have a primary worksite) is within 50 miles (one way) of the government installation where work is being performed under the contract/order. Contractor personnel may obtain authorization (via this form) for reimbursement for local travel costs that exceed their normal commuting costs.

Traveler’s Name: ___________________________________________ Position: __________________________

Purpose of Travel (to include various local locations within trip): ________________________________________ First Day of Travel: ____________________________ Last Day of Travel: ______________________________

Traveler’s Primary Worksite or Their Residence (if they do not have a primary worksite):

(City/ State)

Contract Work Location: ________________________________________________________________________ (City/State)

Mode(s) of Transportation: Privately Owned Vehicle - Est. number of miles round trip per day: __________ Local Transit System (bus, subway) Taxi * Rental Car* (and fuel)

*Provide justification: _________________________________________________________________________ Anticipated Misc. Costs: Parking/Tolls

Other relevant information: _______________________________________________________________

TOTAL ESTIMATED LOCAL TRAVEL COSTS: $______________________

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

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

COR SIGNATURE DATE

CONTRACTING OFFICER (KO) SIGNATURE OR DATE

CONTRACT SPECIALIST (KS) SIGNATURE

Attachment 3