CLAIM FOR TRAVEL EXPENSE SUPREME COURT OF NEVADA 201 S. Carson St., Suite 250, Carson City, NV 89701-4702 Name: Title: Mailing Address: Telephone Number: Facsimile Number: Judicial/Business Affiliation: Official Station (city, state): Employee ID # (state employees only): Traveler is a (check one): Purpose of the Trip: Supreme Court Justice or Supreme Court/AOC Employee Senior Justice or Senior Judge District Court Judge or Employee Municipal or Justice Court Judge or Employee State Executive Branch Agency Employee Judicial Board, Committee or Commission Member Independent Contractor Other Check here if the Supreme Court/Administrative Office of the Courts paid for an airline ticket in relation to this travel claim. Include costs for airline tickets below only if the traveler paid for an airline ticket and is requesting reimbursement. Destination Date (Cities/locations traveled to and from) Time in Travel Status Include a.m. or p.m. Used to determine eligibility for meal reimbursement Began Ended Other Transportation Codes (Does not apply to personal vehicle. See personal vehicle column): (agency vehicle) MP (State Motor Pool car) RC (rental car) GR (ground trans such as taxis, shuttles, subway, city bus, etc.) P (plane) X (passenger in car) Transportation Personal Vehicle # of Miles Driven Daily Expenses Other Trans Cost per Enter mile (either Code from .50 or .25) Above AV $7.00 Cost Breakfast $11.00 $23.00 $5.00 Lunch Total for Meals Dinner Incidental Lodging Total for the Day - - - - - - - - - - - - - - - - - - Airport or Other Parking Fee - - - - - Registration or Other Fee Total Claimed - - - - - - - - Original travel claims and signatures are required to be reimbursed. No fax transmittals are accepted. Maximum amounts to be reimbursed for meals and lodging can be found at www.gsa.gov under the per diem link. Original itemized receipts are required and must be attached to the travel claim in order to be reimbursed for: 1. Airline tickets; 2. Parking; 3. Transportation expenses (rental car, shuttle, taxi, etc.); 4. Lodging over $70 per night; 5. Meals in excess of the standard rates above; and/or 6. Registration or similar expenses associated with the reason for travel. The travel claim must be submitted for reimbursement within 30 days of travel status. Prior approval of travel by the Supreme Court, AOC, and/or the Judicial Education manager, is required in order to be reimbursed for travel to conferences or out-of-state. I declare under penalty of perjury that this claim and accompanying evidence has been examined by me and to the best of my knowledge and belief is a true and correct claim in conformance with Supreme Court and other governing authority statutes and policies. Signature of Traveler Date Date Signature of Approving Authority Please use blue ink when signing or approving this form. This form was approved for use and distribution by the Nevada Supreme Court Jan 2010. American LegalNet, Inc. www.FormsWorkFlow.com -