Applicant/Provider:

Enter the Applicant's legal name.

Period:

Enter the time period for which this budget will cover; usually, this will cover a fiscal year.

Date Prepared

Enter the date this justification was prepared.

NAME OF EMPLOYEE

& TITLE

Enter name and/or position title for individual(s) who will be traveling.

DESTINATION

Enter destination and purpose of travel (e.g., training, provision of services, etc.)  Travel must be directly related to the program.

NO. DAYS

Enter the estimated number of days of travel.

PER DIEM

     A

Enter the per diem or subsistence amount requested (i.e., per diem rate multiplied by the number of days of travel.)  Per diem should be based on the applicant's per diem policy and should not exceed the maximum allowed by the state purchasing agency.

AIR FARE

     B

Enter the cost of airfare.  First-class travel is not allowed.

TRANSPORTATION

     C

Enter the estimated cost of ground transportation, based on the applicant's ground transportation policy.

TOTAL

Enter column totals for columns A, B and C and the total travel cost (A+B+C).  If the purpose of travel relates to two or more programs, costs for the per diem or subsistence, airfare, and taxi/bus/car should be prorated in accord with a cost allocation method approved by the state purchasing agency.

JUSTIFICATION/

COMMENTS:

Justify the need for travel for the delivery of this service activity.  Enter additional explanations.  Attach additional sheets, if necessary.