ࡱ>  @  bjbjqq 4,1K99999999}}}8}L9؀ғǔ` ',S1333333$RW59ÔǔW9944499141447X99߻̀ y}ԧR(m0(& P߻9999999L764m,%WW99dBP|D99P|TRAVEL VOUCHERVoucher NumberFOR NON STATE EMPLOYEESMichigan Department of Human ServicesInvoice NumberAudited ByINSTRUCTIONS:1A. Payee/Vendor Name2. Agency Number3. Checked By4. Page / of FORMTEXT      431 FORMTEXT   FORMTEXT   FORMTEXT   FORMTEXT   FORMTEXT   FORMTEXT       FORMTEXT      B. Address5. Payee Social Security Number6. Prepare Phone No.  FORMTEXT       FORMTEXT      ( FORMTEXT    )  FORMTEXT      C. CityD. StateE. Zip Code7. Period Covered FORMTEXT       FORMTEXT       FORMTEXT      FROM: FORMTEXT      TO: FORMTEXT      8. Payee Type FORMCHECKBOX C.J.O. (FTR-18) FORMCHECKBOX STUDENT (FTR-18) FORMCHECKBOX CONTRACTUAL (FTR-18) FORMCHECKBOX VOLUNTEER (FTR-1632)9. Institution/organization (if applicable) FORMTEXT      10. Message11. Nature of Business TravelTRAVEL EXPENSE REIMBURSEMENT FORMTEXT      12. Day of the Month13.14.Mileage18.Meals21. 22. Travel DescriptionDepartReturn15. Stand.16. Prem.17. Dollar AmountMotel or Room19. Non-Tax.20. TaxableOther Exp.DAILY TOTAL  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT  =(dollar1+motel1+nontax1+tax1+oes1) 0.00.00 FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT  =(dollar2+motel2+nontax2+tax2+oes2) 0.00.00 FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT  =(dollar3+motel3+nontax3+tax3+oes3) 0.00.00 FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT  =(dollar4+motel4+nontax4+tax4+oes4) 0.00.00 FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT  =(dollar5+motel5+nontax5+tax5+oes5) 0.00.00 FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT  =(dollar6+motel6+nontax6+tax6+oes6) 0.00.00 FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT  =(dollar7+motel7+nontax7+tax7+oes7) 0.00.00 FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT  =(dollar8+motel8+nontax8+tax8+oes8) 0.00.00 FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT  =(dollar9+motel9+nontax9+tax9+oes9) 0.00.00 FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT  =(dollar10+motel10+nontax10+tax10+oes10) 0.00.00 FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT  =(dollar11+motel11+nontax11+tax11+oes11) 0.00.00 FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT  =(dollar12+motel12+nontax12+tax12+oes12) 0.00.00 FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT  =(dollar13+motel13+nontax13+tax13+oes13) 0.00.00 FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT  =(dollar14+motel14+nontax14+tax14+oes14) 0.00.00 FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT  =(dollar15+motel15+nontax15+tax15+oes15) 0.00.0023. COLUMN TOTAL % FORMTEXT  =sum(ABOVE) 0.00.00 FORMTEXT  =sum(ABOVE) 0.00.00 FORMTEXT  =sum(ABOVE) 0.00.00 FORMTEXT  =sum(ABOVE) 0.00.00 FORMTEXT  =sum(ABOVE) 0.00.00 FORMTEXT  =SUM(ABOVE) 0.00.00 FORMTEXT  =SUM(ABOVE) 0.00.00 FORMTEXT 024. VOUCHER TOTAL ....................%$ FORMTEXT  =sum(above) 0.00.00 I certify that this travel was pre-approved, necessary to accomplish the DHS mission according to executive directive criteria, the most cost effective travel option available and that the items claimed represent proper charges. Check only one box below. FORMCHECKBOX 1. Legal or Federal Mandate FORMCHECKBOX 2. Health & Safety FORMCHECKBOX 3. Budget Savings FORMCHECKBOX 4. Mission Critical Administrative Travel25. Payee SignatureDate26. Approval / Supervisor SignatureDate27. Distribution Method28. Agency Code29. Approp. Year30. Index Code31. Program Cost Account (PCA)32. Agency Object Code (AOBJ)33. Distribution Code ($ Amount)  FORMCHECKBOX SINGLE431 FORMTEXT    FORMTEXT       FORMTEXT       FORMTEXT      $ FORMTEXT 0.00 FORMCHECKBOX MULTIPLE431 FORMTEXT    FORMTEXT       FORMTEXT       FORMTEXT      $ FORMTEXT 0.00(Enter Dollar Amounts in Column 36)431 FORMTEXT    FORMTEXT       FORMTEXT       FORMTEXT      $ FORMTEXT 0.00431 FORMTEXT    FORMTEXT       FORMTEXT  <>n f      ( * , . 0 2 4 H J L N P R T h j l n p t v jh`Uj{h`Ujh`Ujh`Ujh`UjhD8UmHnHujh`Ujh`U h`CJ h`5 h`>* h`CJh`4<>np8$Ifgkd$$If940-+fa 4 9af4p$If.$Ifl  pr$If+$Ifgkd$$If940-+fa 4 9af4p   ysmm8$If$Ifkdl$$If94F-"+f     4 9af4p  B d f ysssss$Ifkdj$$If94F-"+f     4 9af4p  SMDDDDD 8$$Ifa$8$Ifkdh$$If94r-"+'+f `bc  4 9af4p 2 R r t  J Ff 8$If$If 8$$Ifa$ L N b d f p r v x P R f h j t v x z ڼڱڦڛڐڅjh`Uj4h`Ujh`Uj h`Uj1 h`Uj h`Uh`B*phjh`Uh`jhD8UmHnHujh`Ujeh`U4J L t v qkekk$If8$Ifkd $$If94\-"+f`   4 9af4p  * N }} $$Ifa$$Ifskd$$If94\-"+f f 4 9af4N P x  , ||  $If8$Ifskd]$$If94\ -+& Ta4 9af4      ( * , N P l n p &(DFH|h[+jph >Ujh >Ujh >Ujh >Uh`CJOJQJj h`Ujh`Uj h`Uh`jhD8UmHnHujh`U2, . 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! !!!!!.!0!2!:!!@!T!V!X!`!b!d!f!z!|!~!!!!!!!!!!!!!!!!!!!!!zjhh`CJUjIhh`CJUjgh`CJUj+gh`CJUjfh`CJUjfh`CJUhD8CJmHnHujeh`CJU h`CJjh`CJUjhD8CJUmHnHu0 !>!d!!!!!x"z""""#@#f#####$$$$$$%B%FfCuFfok8$If!!!!!!""^"`"f"h"j"l"t"v"z"|""""""""""""""""""""""# # #####0#2#4#{jUoh`CJUjnh`CJUjinh`CJUjmh`CJUjhD8CJUmHnHujmh`CJUj]ih`CJUh`CJmHnHu h`CJhD8CJmHnHujh`CJU04#<#>#@#B#V#X#Z#b#d#f#h#|#~##########################$$$$ $"$$$&$:$<$$$$$h`CJmHnHujrh`CJUjrh`CJUjqh`CJUjph`CJUjoph`CJUjoh`CJU h`CJjh`CJUhD8CJmHnHu4$$$$$$$$$$$$$$$$$$$$$% % %%%%%0%2%4%>%@%B%D%X%Z%\%d%f%h%j%~%%%%%%׭נד׆yjyh`CJUj)yh`CJUjxh`CJUj=xh`CJUjwh`CJUjhD8CJUmHnHuj]wh`CJU h`CJhD8CJmHnHujh`CJUj1sh`CJU/B%h%%%%&&&L&&&&$'L't'''' (2(X(~()).)V)~)))FfFf18$If%%%%%%%%%%%%%%%%%%%%%&&&&&"&$&&&(&<&>&@&H&J&L&N&b&d&&&&&&&&&&&&j}h`CJUh`CJmHnHuj|h`CJUj{h`CJUji{h`CJUjzh`CJUhD8CJmHnHujGzh`CJU h`CJjh`CJU1&&&&&&&''' '"'$'&':'<'>'H'J'L'N'b'd'f'p'r't'v'''''''''''''''''''''ҸҫҞ҆yj5h`CJUjh`CJUhD8CJmHnHujh`CJUjh`CJUj+h`CJUjh`CJU h`CJjhD8CJUmHnHujh`CJUjKh`CJU/''''(( ( (("($(&(.(0(2(4(H(J(L(T(V(X(Z(n(p(r(z(|(~(((((((((()))))) )*),).)0){jhD8CJUmHnHuj9h`CJUjh`CJUh`CJmHnHujuh`CJUjh`CJUjWh`CJUhD8CJmHnHujDŽh`CJU h`CJjh`CJU00)D)F)H)R)T)V)X)l)n)p)z)|)~)))))))))))))))))))))))* * *****.*0*2*:*<*>*zjh`CJUj#h`CJUjh`CJUhD8CJmHnHujh`CJUjh`CJUjh`CJUjhD8CJUmHnHujh`CJUjh`CJU h`CJ0))*>*d***6+8+`+++++$,J,p,,,,h-j---- .0.V.FfFf 8$If>*@*T*V*X*`*b*d*f*z*|*~**************++$+&+(+*+2+4+8+:+N+P+R+\+^+`+b+v+x+z+++++{jh`CJUjhD8CJUmHnHuj'h`CJUjh`CJUh`CJmHnHujch`CJUj׏h`CJUhD8CJmHnHujEh`CJU h`CJjh`CJU0+++++++++++++++++++++,,,, ,",$,&,:,<,>,F,H,J,L,`,b,d,l,n,p,r,,,,,,,zj3h`CJUjh`CJUjh`CJUjh`CJUhD8CJmHnHujh`CJUj}h`CJUjhD8CJUmHnHujh`CJUjh`CJU h`CJ0,,,,,,,,,,,,,,,,,,N-P-V-X-Z-\-d-f-j-l----------------------{jh`CJUjh`CJUjhD8CJUmHnHujh`CJUjݚh`CJUh`CJmHnHujQh`CJUhD8CJmHnHujřh`CJU h`CJjh`CJU0----.. . . .".$.,...0.2.F.H.J.R.T.V.X.l.n.p.x.z.|.~.....................zjh`CJUj!h`CJUjh`CJUjh`CJUjqh`CJUhD8CJmHnHujh`CJUjhD8CJUmHnHujh`CJUjkh`CJU h`CJ0V.|..../////0<0b00000 1F1112R222633 $$Ifa$FfFf8$If..///////*/,/////////////////////////0000000*0,0.080:0<0>0{jYh`CJUjh`CJUjyh`CJUjhD8CJUmHnHujh`CJUjˤh`CJUh`CJmHnHuhD8CJmHnHuj?h`CJU h`CJjh`CJU0>0R0T0V0^0`0b0d0x0z0|0000000000000000000000000011111 1"16181:1B1D1F1H1\1^111j-h`CJUjh`CJUjh`CJUjh`CJUjh`CJUj_h`CJUhD8CJmHnHujh`CJUjϪh`CJU h`CJ511111111222282:2@2B2D2F2N2P2R2T2h2j222222222222222222222223333$3&3(3*323436383L3jh`CJUjh`CJUjh`CJUjh`CJUh` h`CJhD8CJmHnHujh`CJUjh`CJUh`CJmHnHu:L3N3h3j3p3r3t3v3~333333333333333333444 4 4444440424446484<4`44444烈yuuh`h`CJOJQJhD8<CJmHnHuj1h`<CJU h`<CJjh`<CJUjh`CJUjh`CJUhD8CJmHnHuj]h`CJUh`CJmHnHu h`CJjh`CJU.334:4<4$kd$$If94 _(!$C'+UCCCCCL$$$$4 9af48$If<4b4n4z4444448$If 8$$Ifa$44444444444444u6v66666666666666666666666ļuej̻hD8h >CJUjXhD8h >CJUh~:hOYhxnh~:CJjhD8h >CJUhxnh~DCJjhxnh~DCJUhxnh[+5h`OJQJhD8CJmHnHujh`CJUh`CJmHnHu h`CJjh`CJU%444t6=4( dL$Ifgdxn dkd=$$If94ִ(!$%C'+CCL    4 9af4t6u66666666(7)7=7B7f7k7$IfFfdL$Ifgdxn8dL$IfgdxnLkdU$$If94P++  4 9af4p 6666'7)7B8D8`8b8d8|8~8888888888888888888888999999909{pjdhb*Ujhb*Ujxhb*UjhD8UmHnHujhb*Uhb*jhb*Ujh >UhOGwjhOGwUh`h~:hOYhxnh~:CJjhxnh~DCJUj@hD8h >CJU)k7l7m7n7o7p7$Ifukd$$If94r\Y%+ 4 9af4p7q77777777777778zzzzzzzzzzzz $$Ifa$$Ifukd$$If94"\Y%+ 4 9af48.80828486888:8GA$Ifkd$$If94֞w c#+$$$4 9af4 $$Ifa$:8<8>8@8B8f8GB9 8$$Ifa$dkd$$If94֞w cY#+4 9af4 $$Ifa$f8t8|888899@98$If $$Ifa$ 8$$Ifa$gdb* 8$$Ifa$$If092949<9>9B9R9T9p9r9t9v9999999999999999999999::::::&:(:.:0:D:F:H:P:R:V:ϿϴӦϛӦϐӦυӦzj$hb*Ujhb*Uj8hb*Ujhb*UjhD8UmHnHujLhb*U hb*5jh >Uhb*jhb*Uh`hOGwhD8mHnHujhOGwUjhOGwU0@9B9D9*$$Ifkdv$$If94 w c#$+Uo$$$$$$$4 9af4D9F9H9J9L9N9P9R9Gkd$$If94֞w cY#+4 9af4 $$Ifa$R9v99999:*:.:T:8$If $$Ifa$ 8$$Ifa$gdb*$If 8$$Ifa$ T:V:X:*$$Ifkd$$If94 w c#$+Uo$$$$$$$4 9af4X:Z:\:^:`:b:d:f:Gkd$$If94֞w cY#+4 9af4 $$Ifa$V:f:h:::::::::::::::;;;;;;&;(;*;,;@;B;D;N;P;V;X;l;n;p;x;z;|;~;;;;;;;;;;;;;;jhb*UhD8mHnHujhb*UjLhb*Ujhb*Uj`hb*UjhD8UmHnHujhb*Ujhb*U hb*5hb*h`5f:h::::;*;R;V;|;8$If $$Ifa$ 8$$Ifa$gdb*$If 8$$Ifa$ |;~;;*$$Ifkd^$$If94 w c#$+Uo$$$$$$$4 9af4;;;;;;;;Gkd$$If94֞w cY#+4 9af4 $$Ifa$;;;;;; 48^8$If $$Ifa$ 8$$Ifa$gdb*$If 8$$Ifa$ ;;;;;;;;;;< "$&028:NPRZ\^`pFH\^`dfhj~ڷکښڏڄjhb*Uj(hb*Ujhb*Uh` hb*5hD8mHnHujhb*Uj0hb*UUjhb*Uhb*jhD8UmHnHujhb*UjDhb*U4     FORMTEXT      $ FORMTEXT 0.00NOTE: DO NOT use the coding portion if more than 6 line  Use the Supplemental Coding Record DHS-4745431 FORMTEXT    FORMTEXT       FORMTEXT       FORMTEXT      $ FORMTEXT 0.00431 FORMTEXT    FORMTEXT       FORMTEXT       FORMTEXT      $ FORMTEXT 0.0034. TOTALS %$ FORMTEXT  =(Distribution1+Distribution2+Distribution3+Distribution4+Distribution5+Distribution6) 0.00.00 Distribution: Original  Send to DHS Accounting Retain copy for your files INSTRUCTIONS- THIS FORM IS TO BE USED ONLY BY NON-STATE EMPLOYEES; PLEASE SEE 1582-TV FOR STATE EMPLOYEE TRAVEL VOUCHER: Travel related information is available in the DHS Administrative handbook Section Series 800. Improper or incomplete Travel Vouchers may be returned and require resubmission. It is especially important to assure the account coding structure is accurate and that the travel voucher is properly authorized. The payee address cannot be a DHS location. 1A Enter last name, first name, middle initial. Thirty characters are allowed for Payee name. 1B Enter address. 1C Enter city name in full unless a commonly used abbreviation such as N.Y. for New York, etc., is recognized. 1D Enter the two-digit abbreviation only. DO NOT USE full state name. 1E Enter zip code. 2 Enter Index Code after 431, EXCEPT for Residential Cares and Institutions which have been assigned special Dept. No. 3 Initials of person that checks the voucher. 4 Enter page number of document(s). Use DHS SUPPLEMENTAL CODING RECORD (DHS-4745) if needed. 5 Enter payee s full 9 digit Social Security Number. 6 Enter preparer s phone number. 7 FROM: Enter begin travel month and date. TO: Enter end travel month and date. 8 Check appropriate box. Only 1. 9 Institution/organization (if applicable). 10 DO NOT USE - MESSAGE IS PREPRINTED. 11 Enter nature of business travel for this period. 12 Enter date of travel. 13 The description may be the departure and return to the local office of the department, the size of volunteer activity/event, or the client s home. When a client s home, indicate client s last name, address and case number. Indicate the nature of business requiring travel and specify departure and destination, include city of call. 14 Enter time of departure and return for each trip to substantiate meal, lodging and any day care charges. 15-17 Enter MILEAGE* for the use of privately owned cars on state business. Enter the number of map miles traveled (MI Dept. of Transportation map or Rand McNally for out-of-state) rounding to the nearest whole mile. Vicinity mileage in connection with the trip is allowable when shown as a separate item on the voucher. Multiply total miles by applicable reimbursement rate and enter in dollar amount column. *Refer to departmental guidelines or procedures of guidance in the use of the standard and premium mileage rates. 18 Enter the actual lodging cost but not to exceed the current state rate. Receipts for lodging expenses are required when reimbursement is requested on an actual basis. 19-20 Enter total for meal(s) per day. Non-taxable indicate those meals you paid when your trip included overnight lodging. Taxable indicate those meals you paid for when you did not have overnight lodging. 21 Itemize and identify dollar amounts of the other expenses, e.g., bus fare. Receipts for registration, child care, and parking expenses, etc., except meter parking, are required by the Standardized Travel Regulations. (Meter parking costs will be identified by entering M.P.). 22 Enter the total, per day, of columns 19, 20, 21, 22 and 23. NOTE: Within the block containing columns 14 thru 24, when charging the premium mileage rate, you must indicate one of the authorized circumstances for such charge as listed in Item 812 of the Administrative Handbook. 23 Enter totals of Columns 17, 18, 19, 20, 21, 22, 23, 24. 24 Enter total of Column 24. 25 Payee, sign and date. - ORIGINAL SIGNATURE IS REQUIRED 26 Original Signature of the individual authorizing payment. Signature stamps are not acceptable. Print or type the individual s name below the signature. Enter date the voucher was signed. CODING INSTRUCTIONS: Assure that the Index Code, Program Cost Account, Agency Object are correct. All coding must pass an edit. Incompatible coding will error out. 29 Enter appropriation year. 30 Enter the Index Code to which the expenditure should be charged. This MUST be compatible with the PCA #. 31 Enter the Program Cost Account to which the expenditures should be charged. Use a Supplemental Coding record, if more than 6 lines are used. ALL coding if more than 6 lines, must be on the Supplemental Coding record. 32 Enter the Agency Object Code to identify the type of travel expenses incurred. 33 Enter the amount charged to each account structure. 34 Enter the total amount paid, the sum of all lines of entry in box 36. 35. When signing the travel voucher, you are verifying that the travel was pre approved and necessary to accomplish the DHS mission according to the executive directive criteria. You must check only one of the four categories certifying that costs have been incurred in accordance with Executive Directive 2007-19 Travel Moratorium. AUTHORITY: 42 CFR; and Public Act 280 of 1939, as amended. RESPONSE: Voluntary. PENALTY: NoneDepartment of Human Services (DHS) will not discriminate against any individual or group because of race, sex, religion, age, national origin, color, height, weight, marital status, sexual orientation, political beliefs or disability. If you need help with reading, writing, hearing, etc., under the Americans with Disabilities Act, you are invited to make your needs known to a DHS office in your area. DHS-1582-TV-NSE (Rev. 3-08) Previous edition obsolete. 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