Per Diem Request Form

Request form for per diem reimbursement or advance based on GSA rates, including travel location, trip duration, lodging, meals, and incidental expenses.

Request Type

• Request type
• Trip purpose
  Briefly describe the business purpose of the trip. Keep this to the minimum necessary for audit trail purposes.
• Trip approval reference
  Optional approval or travel authorization number, if your organization uses one.

Traveler and Destination

• Traveler name
  Enter the name of the traveler submitting this request or the traveler on whose behalf it is being submitted.
• Department
  Optional department or team for internal routing.
• Destination city
  Enter the primary travel city or locality used for GSA rate lookup.
• Destination state or region
  Optional state, province, or region if needed to identify the correct locality.
• Is the lodging location the same as the destination locality?
• Lodging location
  Shown only if lodging is in a different locality than the destination. Enter the city/locality used for lodging rate calculation.

Trip Dates and Duration

• Departure date
• Return date
  The date the traveler returned or will return from the trip.
• Number of overnight stays
  Enter the total number of nights away from home.
• Number of travel days
  Optional total number of days for internal review.

Lodging, Meals, and Incidentals

• Was lodging provided by the host or covered separately?
• Were any meals provided at no cost?
  Select all meals that were provided and should be excluded from the per diem calculation.
• Are incidental expenses included in this request?
• Incidental expenses amount
  Enter the incidental amount requested, if applicable and allowed by policy.
• Special rate or exception notes
  Use this field only if the request needs a policy exception, split locality rate, or other explanation for review.

Payment Details and Attestation

• Preferred payment method
• Employee ID
  Optional internal identifier for routing and audit trail. Do not enter SSN or other sensitive identifiers.
• Consent and accuracy acknowledgement
  I confirm the information provided is accurate, I understand this form may be used for audit trail and payment processing, and I consent to the collection of the PII entered here for that purpose.