Name:	Employee NIS No.:	State of Nebraska Department of Transportation Expense Reimbursement Request	Originating O.E.:	NDOT Document No.:
Address:
Checklist for Expense Vouchers: https://dotspot.nebraska.gov/divisions/controller/publications Click on Expense Voucher Checklist
TRANSACTION TYPE
WARRANT WRITING
Title:
Headquarters:	NDOT Vehicle License No.:
Date Mo/Da/Yr	PARTICULARS	TRAVEL TIME	MEALS (Actual Amts. Only)	LODGING	PERSONAL VEHICLE USAGE	MISCELLANEOUS	TOTAL
NAME OF PLACE AND NATURE OF SERVICE
RATE	MILES	AMOUNT
Transaction Code	Fund	O.E.	Activity	District Equipment Yard, Radio, Scale Building, Etc.	PROJECT	AFE or Premix Site Number
NUMBER	UNIT	Trip Started	Trip Completed	In-State Acct. #4713 Out of State Acct. #4712	In-State Acct. #4743 Out of State Acct. #4742	Description
BRIDGE	Account	Amount
HIGHWAY NO.	REFERENCE POST
FROM	TO
Purpose:	a.m. p.m.	a.m. p.m.	B	$	$	$	$ 0.00	$ 0.00
Origin, Stops, and Destination:	L	$	Motel:
1311	2270	D	$	Account #
Acct. #:
Purpose:	a.m. p.m.	a.m. p.m.	B	$	$	$	$ 0.00	$ 0.00
Origin, Stops, and Destination:	L	$	Motel:
1311	2270	D	$	Account #
Acct. #:
Purpose:	a.m. p.m.	a.m. p.m.	B	$	$	$	$ 0.00	$ 0.00
Origin, Stops, and Destination:	L	$	Motel:
1311	2270	D	$	Account #
Acct. #:
Purpose:	a.m. p.m.	a.m. p.m.	B	$	$	$	$ 0.00	$ 0.00
Origin, Stops, and Destination:	L	$	Motel:
1311	2270	D	$	Account #
Acct. #:
Purpose:	a.m. p.m.	a.m. p.m.	B	$	$	$	$ 0.00	$ 0.00
Origin, Stops, and Destination:	L	$	Motel:
1311	2270	D	$	Account #
Acct. #:
Directly Billed Motel Name	City	State	TOTALS	$ 0.00	$ 0.00	$ 0.00	0.00	$ 0.00
DB: 1
DB: 2	Use of private vehicle authorized by:
DB: 3	District/Division Approval:	Date:
DB: 4
I claim reimbursement from the State of Nebraska for the above expenses incurred by me in the line of duty and declare that the above statement of them is a true account of such expenses for which payment has not been made heretofore by the State of Nebraska.	Signature: Employee Other	Date:

NDOT Form 117, January 2018	Distribution: D.A.S./Controller – District/Division – Employee