Missouri Department of social services Children’s Division Travel expense log for Level B foster Youth
Fields 1 through 15 on this form are to be completed by the Resource Provider requester. Requests must be submitted to the worker within 30 days of the month when trip occurred. This form is child specific. If more than one child is transported for reimbursement, the cost of the transportation must be split between each child transported.
1. Travel for the Month of , 20
2. Resource Parent(s):	3. DVN	4. Vender Type: CF
5. Address:
6. Child’s Name:	7. DCN
8. Worker:	9. Office Address:	Phone:
10. Date of Travel (MM/DD/YY)	11. Address of Destination (street, city, zip code)	12. Purpose of Travel	13. # Miles Round Trip	14.Level B Deduction	15. # Of Miles Allowed for Reimbursement
200
200
200
200
Resource Provider Signature:	Date:
Total Miles Allowed	BOX A
Current Mileage Rate at Time of Trip	BOX B ¢
TOTAL Amount Reimbursed	BOX C $
Worker checks for accuracy and completes Box A, B, C, and D	Ongoing Travel Approval Effective Begin and End date: daily weekly monthly copy of original approval attached	BOX D MM/DD/YY MM/DD/YY
Worker Approval: DATE: Supervisor Approval: DATE:
Circuit Manager / or Circuit Manager Designee IN THE METRO AREAS APPROVAL: DATE:

Travel Expense Log

CD-107

PURPOSE:

This form is designed to provide a method for requesting reimbursement of allowable transportation costs of Level B resource providers. The form is a child specific form to address the reimbursable travel for the specified level B foster youth for the month specified. Only one foster youth is to be entered on the form. Accuracy and adherence to policy requirements and limitations are essential to be compliant with auditing programs. The reimbursement is at the current state mileage rate at the time of the travel using a Payment Request, PR.

The Level B resource provider may be reimbursed at a per mile state rate for Level B foster youth specific transportation that is over a 200 mile round trip with Circuit Manager or Circuit Manger Designee in the metro areas approval only.

*EXCEPTION: Education-related transportation needed to maintain the child in his/her school of origin. (The Level B provider will use the CD-106 to claim education-related transportation)

For cases that require frequent approval, the determination can be made at a Family Support Team meeting and a standing approval be granted for that frequent child specific trip. The written approval from the Circuit Manager or Circuit Manager Designee in the metro areas is identified by their signature on the CD-107. The PR with the CD-107 attached is submitted to the FACES Payment Unit to process for reimbursement.

Round Trip

A round trip is defined as leaving from point “A”, traveling to point “B” and returning to point “A”. Some round trips may not include the foster youth in the vehicle on the return trip, as when a youth is being dropped off to be picked up at a later time.

NUMBER OF COPIES AND DISTRIBUTION:

The CD-107 is attached to the PR.

The PR is completed by the worker, approved by the supervisor, entered in the system, and sent to the FACES Payment Unit for reimbursement.

The CD-107 must be submitted to FACES Payment Unit with all required signatures.

A copy of the CD-107 is provided to the resource provider before submitting the paper work to the Payment Unit.

A copy of the PR with the CD-107 attached is filed in the centralized filing location which is determined locally.

Neither the CD-107, nor the PR is to be placed in the resource provider case file due to the child specific information.

INSTRUCTIONS FOR COMPLETION:

The form is formatted to be completed electronically on-line, but may be printed and written by hand if desired. Fields 1 through 15 of the form are completed by the resource provider and reviewed for accuracy by the worker. The worker completes Boxes A, B, C, and D.

Resource Provider:

Field 1: Enter the month using the drop down box and the year that the travel occurred.

Field 2: Enter the name(s) of the resource parent(s).

Field 3: Enter the Department Vendor Number, DVN.

Field 4: Default for Level B resource providers; CF

Field 5: Enter the complete address including street address, city and zip code of the resource provider.

Field 6: Enter the name of the foster youth.

Field 7: Enter the youth's Department Client Number, DCN.

Field 8: Enter the name of the worker.

Field 9: Enter the office address and phone number.

Field 10: Enter the date that the travel occurred.

Field 11: Enter the complete address of the destination. This information must include street address, city, and zip code.

Field 12: Enter the purpose of the trip.

Field 13: Enter the total round trip miles.

Field 14: Default 200 mile deduction for Level B resource providers.

Field 15: Enter the amount of miles charged to the foster youth's DCN. This is the total round trip miles minus 200.

The resource provider must sign and date the form and submit to the worker within thirty (30) days of the month that the trip occurred.

When there is more than one youth being transported for a trip, the trip mileage must be divided between each of the youth that were on the trip. This is a Federal, IV-E requirement.

Worker

In BOX A, enter the total number of miles charged to the DCN.

In BOX B, enter the current mileage rate at time of trip.

Multiply the total number of allowable miles by the current mileage reimbursement rate at the time of the travel.

In BOX C, enter the dollar amount that resulted from the multiplication of Box A and Box B.

BOX D is used if an on-going trip has been approved. Enter the approval begin date and an end date that the approval is valid through and check the appropriate box of the reoccurrence being daily, weekly, or monthly.

The worker will attach a copy of the originally approved CD-107 each time the CD-107 is submitted for the approved on-going trip.

The worker will review the form for accuracy.

The worker will sign and date the CD-107 substantiating accuracy of the data entered and submit to the supervisor for approval.

Submit to supervisor for approval signature

The supervisor will validate the accuracy of the documents, sign and date the CD-107.

Submit to Circuit Manger, or Circuit Designee in the metro areas if applicable.

The CD-107 is not complete until all required signatures are entered on the form.

The payment is entered into the system and then the documents, PR and CD-107, are sent to the FACES Payment Unit.

The worker will be sure that the CD-107 is attached to the PR.

The worker will make a copy of the CD-107 and provide the copy to the resource provider prior to sending the form(s) to the FACES Payment Unit.

File the original copy of the documents in the designated centralized location for all Payment Requests.

Memo: CD08-106, CD 09-65, CD09-85, CD09-95, CD09- 126, CD11-49, CD13-27