Travel-Only Reimbursement Form for Short-Term Visitors

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Please convert amounts in foreign currencies to US Dollars. Be sure to use the date of purchase for the conversion. You can convert foreign currencies here: http://www.oanda.com/currency/converter.

Traveler information

Passport/Legal First Name

Passport/Legal Last Name

Phone number

Phone number, starting with area code

Home street address 1

Please enter your home address. Do not use your temporary Berkeley address.

Home street address 2

City

State

Zip code

Country

Please indicate your status:

UC Berkeley EmployeeUC Berkeley StudentEvent or workshop participantOther

Please enter your UC Berkeley student or employee or other UC Berkeley ID number:

Are you a US citizen or green card holder?

Yes, I am a US citizen.No, I am not a US citizen.I am a permanent resident and hold a green card.

Please upload your Visa Passport Page, I-94 (if applicable), and visa stamp. Click "Add another response" if you need to upload more than one document.

Green card holders, please upload a scan of your green card here:

Were you traveling on a WT (Waiver-Tourist), WB (Waiver-Business), B1 or B2 Visa? (This is the case for most short-term visitors.)

YesNo

If you haven't done this already: Please complete and upload the Electronic Funds Transfer Authorization form if you would like us to deposit the requested amount in your U.S. bank account. You will receive your reimbursement in US Dollars. You will receive your reimbursement in US Dollars. For a wire transfer to a foreign bank account (instead of mailed paper check), please make sure to fill out the wire transfer request form .

Trip information

Trip purpose (enter the name of the program or workshop you attended)

Trip destination

When did you leave home or the office?

Date

Time

Please us the following format: HH:MM

A.M.P.M.

When did you return home or to the office?

Date

Time

Please use the following format: HH:MM

A.M.P.M.

Receipts:

Make sure your airfare claim/itinerary for reimbursement shows your itinerary and that it has been paid. You must submit receipts for individual expenses of $75 or more. Receipts are required for all domestic lodging and rental car expenses regardless of the cost. Your airfare receipt must include your itinerary as well as your seat class (coach or economy). You may submit the receipt and itinerary as separate documents if you prefer.

Receipts must indicate:

whom you paid (name of the person or company you paid)
the amount you paid and type of currency
when you paid (transaction date)
what you bought (itemized description of goods or services purchased)
how you paid (cash, check, or credit card)

Please upload your receipts here as a page. Click "Add Another Page of Receipts" on the right if you need to upload more than one page.

International visitors, please note:

You will receive your reimbursement in US Dollars. If you prefer a wire transfer over a paper check, please make sure to fill out the wire transfer request form.

Please upload the wire transfer request form here:

If you have any additional comments or information, please write them below.

Questions? Contact David Wurtele at +1 510.664.4029 or simons-reimbursements@berkeley.edu.

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