Travel Advance Request Form - Maryland

This "Travel Advance Request Form" is a document issued by the Maryland Department of Health specifically for Maryland residents with its latest version released on February 1, 2008.

Download the up-to-date fillable PDF by clicking the link below or find it on the forms website of the Maryland Department of Health.

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TRAVEL ADVANCE REQUEST
TO: Cashier's Section
OUT OF STATE REQUEST #________________
Division of General Accounting
201 W. Preston Street
ADVANCE NEEDED BY:_______________
Room 540
FROM:
____________________________________
FISCAL APPROVAL: ___________________________
PCA:__________________INDEX:__________
Employee's Name: ______________________________________ DHMH - Regular Employee ___ Special Pymts Employee ___
Home Address: __________________________________ City: ______________________ State: _____ Zip: _________
Employee Office Location: _________________________________ Office phone number: _________________________
Supervisor's Name: _______________________________________ Office phone number: ________________________
Travel Destination: _________________________
Date of Travel: FROM ___________ THROUGH _____________
Purpose:
___________________________________________________________________________________________
DETAIL OF TRAVEL ADVANCE REQUEST:
MEAL
Number of days ____________ X rate allowed _________________ = TOTAL __________________
LODGING Number of days ____________ X rate charged _________________= TOTAL __________________
OTHER
Parking, taxi, etc.
TOTAL __________________
REGISTRATION*** Attach original application form)
TOTAL __________________
$_________________
TOTAL OF TRAVEL ADVANCE REQUEST
*** Registrations requests over $100.00 must be submitted on a Registration Request Form.
*******************************************************************************************************************************************************************************
PLEASE READ BEFORE SIGNING
I understand, in accepting this temporary advance, that I MUST SUBMIT TO THE DIVISION OF GENERAL ACCOUNTING(DGA) MY EXPENSE
ACCOUNT WITHIN FIVE (5) CALENDAR DAYS AFTER THE COMPLETION OF THE TRIP, with all receipts attached, along with any unused funds.
If General Accounting does not receive the above within five (5) days, DGA will request Human Resources to capture my payroll check to settle the
advance. DGA will also request Human Resources to capture my payroll check to setttle any balance due after receipt and audit of my Expense
Account. I will receive one (1) notice from DGA prior to this capture, giving me an opportunity to explain why the capture should not proceed.
My failure to respond timely to the notice shall constitute a waiver of my right to be heard. If I do request a hearing, DGA will provide me with its
determination in writing after I have been heard.
I certify that I am a current regular payroll/special payroll employee of the Department of Health and Mental Hygiene
I HAVE READ AND UNDERSTAND THIS AGREEMENT
_______________________________________________________
_____________________
Employee Signature
Date
General Acctg Use
WFReview ________Travel Approved _________ Check No ____________ Amount ___________
Revised 2-08
TRAVEL ADVANCE REQUEST
TO: Cashier's Section
OUT OF STATE REQUEST #________________
Division of General Accounting
201 W. Preston Street
ADVANCE NEEDED BY:_______________
Room 540
FROM:
____________________________________
FISCAL APPROVAL: ___________________________
PCA:__________________INDEX:__________
Employee's Name: ______________________________________ DHMH - Regular Employee ___ Special Pymts Employee ___
Home Address: __________________________________ City: ______________________ State: _____ Zip: _________
Employee Office Location: _________________________________ Office phone number: _________________________
Supervisor's Name: _______________________________________ Office phone number: ________________________
Travel Destination: _________________________
Date of Travel: FROM ___________ THROUGH _____________
Purpose:
___________________________________________________________________________________________
DETAIL OF TRAVEL ADVANCE REQUEST:
MEAL
Number of days ____________ X rate allowed _________________ = TOTAL __________________
LODGING Number of days ____________ X rate charged _________________= TOTAL __________________
OTHER
Parking, taxi, etc.
TOTAL __________________
REGISTRATION*** Attach original application form)
TOTAL __________________
$_________________
TOTAL OF TRAVEL ADVANCE REQUEST
*** Registrations requests over $100.00 must be submitted on a Registration Request Form.
*******************************************************************************************************************************************************************************
PLEASE READ BEFORE SIGNING
I understand, in accepting this temporary advance, that I MUST SUBMIT TO THE DIVISION OF GENERAL ACCOUNTING(DGA) MY EXPENSE
ACCOUNT WITHIN FIVE (5) CALENDAR DAYS AFTER THE COMPLETION OF THE TRIP, with all receipts attached, along with any unused funds.
If General Accounting does not receive the above within five (5) days, DGA will request Human Resources to capture my payroll check to settle the
advance. DGA will also request Human Resources to capture my payroll check to setttle any balance due after receipt and audit of my Expense
Account. I will receive one (1) notice from DGA prior to this capture, giving me an opportunity to explain why the capture should not proceed.
My failure to respond timely to the notice shall constitute a waiver of my right to be heard. If I do request a hearing, DGA will provide me with its
determination in writing after I have been heard.
I certify that I am a current regular payroll/special payroll employee of the Department of Health and Mental Hygiene
I HAVE READ AND UNDERSTAND THIS AGREEMENT
_______________________________________________________
_____________________
Employee Signature
Date
General Acctg Use
WFReview ________Travel Approved _________ Check No ____________ Amount ___________
Revised 2-08

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