Claim for Reimbursement for Expenditures on Official Business
CLAIM FOR REIMBURSEMENT
FOR EXPENDITURES
ON OFFICIAL BUSINESS |1. DEPARTMENT OR ESTABLISHMENT, BUREAU, DIVISION OR
OFFICE |2. VOUCHER NUMBER | |
| | | |
| | |3. SCHEDULE NUMBER |
| | | |
|Read the Privacy Act Statement on the back of this form. |5. PAID BY |
|4. |a. NAME (Last, first, middle initial) |b. SOCIAL SECURITY NUMBER | |
|CLAI| | | |
|MANT| | | |
| | | - - | |
| |c. MAILING ADDRESS (Include ZIP Code) |d. OFFICE TELEPHONE | |
| | |NUMBER | |
| | | | |
|6. EXPENDITURES (If fare claimed in col. (g) exceeds charge for one person, show in col. (h) the number of additional persons which accompanied the claimant.) |
|DATE |C |Show appropriate code in col. (b): |MILEAGE |AMOUNT CLAIMED |
| |O |A - Local travel |RATE | |
| |D |B – Telephone or telegraph, or | | |
| |E |C – Other Expenses (itemized) | | |
| | | | |MILEAGE |FARE |ADD. |TIPS AND |
| | | | | |OR TOLL |PER- |MISCEL- |
| | | | | | |SONS |LANEOUS |
|20 | |
| |PAYMENT DESIRED |Sign Original Only |
| | | | |Sign Original Only |
| | | | |a. PAYEE (Signature) |b. DATE |
|9. This claim is certified correct and proper for payment. | | |
| | | | |Sign Original Only | | |
| |( | | |12. PAYMENT MADE | |
| | | | |BY CHECK NO. | |
|ACCOUNTING CLASSIFICATION |
| |
| STANDARD FORM 1164 (REV. 11-77) |
|Prescribed by GSA, FPMR (CFR 41) 101-7 |
|6. EXPENDITURES - Continued |
|DATE |C |Show appropriate code in col. (b): |MILEAGE |AMOUNT CLAIMED |
| |O |A - Local travel |RATE | |
| |D |B – Telephone or telegraph, or | | |
| |E |C – Other Expenses (itemized) | | |
| | | | |MILEAGE |FARE |ADD. |TIPS AND |
| | | | | |OR TOLL |PER- |MISCEL- |
| | | | | | |SONS |LANEOUS |
|20 |
| STANDARD FORM 1164 (REV. 11-77) BACK |
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