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AUTHORIZATION / REQUEST FOR OUT OF STATE TRAVEL
State Form 823 (R9 / 4-09) Approved by State Board of Accounts, 2009

1. Name of agency & division 4. Name of employee (last name, first name, middle initial) 7. Origin of trip 12. Destination of trip 8. Date and time of departure 13. Date and time of return 5. Position / title

2. Date of request (month, day, year )

3. Agency request number

6. Personal time or weekend added? Dates: 10. Trip necessary to fulfill job duties? 11. Attending a conference? 15. Contact person: 16. Contact number:

Y Y Y

N N N

9. Date and time meeting starts 14. Date and time meeting ends

17. Purpose of travel (Use this space to give justification for the trip and why it is in interest of the State that the travel be approved. Provide additional sheet, if necessary.)

ESTIMATED EXPENSES
18. Registration fees 19. Transportation Air Bus Train State car

RATE $ $ $ 0.44 $ $ $

AMOUNT

Automobile (personal) Automobile (rental) 20. Lodging (including taxes) Hotel name & city

___

Miles X

0.00

(attach justification and cost) $ Number of days ___ X Number of days ___ X $

0.00

21. Daily subsistence (per diem) 22. Other expenses 23. Explanation (explain below )

$

$ $ 24. Total Cost $

0.00

0.00

25. Fund Center Name: General Fund Federal Funds Dedicated Fund Other Source % State Funds % Federal Funds % Dedicated Funds % Other Source

26. Fund Center Number:

0.00% 0.00% 0.00% 0.00%

x total cost x total cost x total cost x total cost

= = = =

$ $ $ $ TOTAL cost: $

I certify the requested travel is in furtherance of State business except as indicated above and that my reimbursable expenses will be limited to the amounts indicated above. 27. Signature of traveler 28. Signature and title of approving agency official Date of signed (month, day, year ) Date of signed (month, day, year )

AUTHORIZATION
Authorization to travel out of state will be granted only if all approval signatures below have been acquired Signature of Commissioner, Department of Administration Date of signed (month, day, year )