Agency Code:	411	Agency Name:	Virginia Department of Forestry
SECTION 1 – Employee and Relocation Information
Reimbursement Number:	Is this the Final Reimbursement?	Yes	No
Employee Name:	Employee ID No.:
New Address:
City:	State:	Zip:
Date Employed:	Date Tenure Agreement Signed:
SECTION 2 – Expense Summary
Type of Moving Expense	Total this Report	Total All Prior Reimbursements	Cumulative Total Reimbursements
Taxable Expenses:
Pre-Move House-hunting Travel and Lodging Payments Excluding Meals	No. of Trips	No. of Nights:
Temporary Quarters Travel and Lodging Payments	Date From:	Date To:
Total Meal Payments for Pre-Move House Hunting and Temporary Quarters
Total Meal Payments Incurred During Travel from Old to New Home
Storage Common Carrier	Date From:	Date To:
Storage Other Than Common Carrier	Date From:	Date To:
Qualified Expenses of Buying New Home
Qualified Expenses of Selling Old Home
Other Payments (specify on an attached sheet)
Subtotal Taxable Expenses:
Non-Taxable Expenses:
Transportation – Common Carrier
Transportation Other Than Common Carrier (Moving Vehicle Rental)
Travel and Lodging Payments Excluding Meals for Move from Old to New Home
Subtotal Non-Taxable Expenses:
Grand Total:
SECTION 3 – Employee Certification
I certify that the expenses were incurred by me while moving and relocating at the request of the Commonwealth of Virginia, Department of Forestry.
VDOF Employee Name (Print)	VDOF Employee Signature	Date
SECTION 4 – State Forester Certification
I certify that the expenses were incurred in an employee relocation requested by the Commonwealth of Virginia and do not exceed the requirements set forth in the DOA Moving and Relocation Expense Regulations. Written approval for reimbursement above normal established limits is attached (if reimbursement is above established limits).
Robert W. Farrell
State Forester Name (Print)	State Forester Signature	Date