SF1012-77a
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7. TRAVEL AUTHORIZATION TRAVEL VOUCHER (Read the Privacy Act Statement on the back) 1. DEPARTMENT OR ESTABLISHMENT, BUREAU, DIVISION, OR OFFICE 2. TYPE OF TRAVEL TEMPORARY DUTY PERMANENT CHANGE OF STATION 3. VOUCHER NO. 4. SCHEDULE NO. a. NAME (Last, first, middle initial) c. MAILING ADDRESS (Include ZIP Code) e. PRESENT DUTY STATION b. SOCIAL SECURITY NUMBER d. OFFICE TELEPHONE NO. 6. PERIOD OF TRAVEL a. FROM b. TO f. RESIDENCE (city and State) a. NUMBER(S) b. DATE(S) 10. CHECK NO. 8. TRAVEL ADVANCE 9. CASH PAYMENT RECEIPT 11. PAID BY a. Outstanding b. Amount to be applied c. Amount due Government (Attached: Check Cash) d. Balance outstanding c. PAYEE'S SIGNATURE 12. GOVERNMENT TRANSPORTATION REQUEST, OR TRANSPORTATION TICKETS, IF PUR- CHASED WITH CASH (List by number below and attached passenger coupon; if cash is used show claim on reverse side.) I hereby assign to the United States any right I may have against any parties in connection with reimbursable transportation charges described below, purchased under cash payment procedures (FPMR 101-7). AGENT'S VALUATION OF TICKET (a) ISSUING CARRIER (Initials) (b) MODE, CLASS OF SERVICE AND ACCOM- MODATIONS (c) DATE ISSUED (d) POINTS OF TRAVEL FROM (e) TO (f) a. DATE RECEIVED b. AMOUNT RECEIVED $ 13. I certify that this voucher is true and correct to the best of my knowledge and belief, and that payment or credit has not been received by me. When applicable, per diem claimed is based and the average cost of lodging incurred during the period covered by this voucher. TRAVELER SIGN HERE DATE AMOUNT CLAIMED $ NOTE; Falsification of an item in an expense account works a forfeiture of claim (27 U.S.C. 2514) and may result in a fine of not more than $10,000 or imprisonment for not more than 5 years or both (18 U.S.C. 287; i.d. 1001). 14. This voucher is approved. Long distance telephone calls, if any, are certified as necessary in the interest of the Government. (NOTE: If long distance telephone calls are included, the approving official must have been authorized in writing by the head of the department or agency to so certify. (31 U.S.C. 680a). APPROVING OFFICIAL SIGN HERE DATE 17. FOR FINANCE OFFICE USE ONLY COMPUTATION a. DIFFER- ENCES, IF ANY (Explain and show amount) $ 15. LAST PRECEDING VOUCHER PAID UNDER SAME TRAVEL AUTHORIZATION a. VOUCHER NO. b. D.O. SYMBOL c. MONTH & YEAR 16. THIS VOUCHER IS CERTIFIED CORRECT AND PROPER FOR PAYMENT AUTHORIZED CERTIFYING OFFICIAL SIGN HERE DATE 18. ACCOUNT CLASIFICATION b. TOTAL VERIFIED CORRECT FOR CHARGE TO APPROPRIATION c. APPLIED TO TRAVEL ADVANCE (Appropriation symbol): Certifier's Initials: $ d. NET TO TRAVELER $ $ NSN 7540-00-634-4180 STANDARD FORM 1012 (REV. 10-77) Prescribed by GSA, FPMR (41 CFR) 101-7 Traveler's Initials 5. TRAVELER (PAYEE)
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SF1012-77a
Transcript of SF1012-77a
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7. TRAVEL AUTHORIZATION
TRAVEL VOUCHER (Read the Privacy Act
Statement on the back)
1. DEPARTMENT OR ESTABLISHMENT, BUREAU, DIVISION, OR OFFICE
2. TYPE OF TRAVEL
TEMPORARY DUTY
PERMANENT CHANGE OF STATION
3. VOUCHER NO.
4. SCHEDULE NO.
a. NAME (Last, first, middle initial)
c. MAILING ADDRESS (Include ZIP Code)
e. PRESENT DUTY STATION
b. SOCIAL SECURITY NUMBER
d. OFFICE TELEPHONE NO.
6. PERIOD OF TRAVELa. FROM b. TO
f. RESIDENCE (city and State)
a. NUMBER(S) b. DATE(S)
10. CHECK NO.
8. TRAVEL ADVANCE 9. CASH PAYMENT RECEIPT 11. PAID BYa. Outstanding
b. Amount to be appliedc. Amount due Government
(Attached: Check Cash)d. Balance outstanding
c. PAYEE'S SIGNATURE
12. GOVERNMENT TRANSPORTATION REQUEST, OR TRANSPORTATION TICKETS, IF PUR- CHASED WITH CASH (List by number below and attached passenger coupon; if cash is used show claim on reverse side.)
I hereby assign to the United States any right I may have against any parties in connection with reimbursable transportation charges described below, purchased under cash payment procedures (FPMR 101-7).
AGENT'S VALUATION OF TICKET
(a)
ISSUING CARRIER (Initials)
(b)
MODE, CLASS OF SERVICE
AND ACCOM- MODATIONS
(c)
DATE ISSUED
(d)
POINTS OF TRAVEL
FROM (e)
TO (f)
a. DATE RECEIVED b. AMOUNT RECEIVED
$
13. I certify that this voucher is true and correct to the best of my knowledge and belief, and that payment or credit has not been received by me. When applicable, per diem claimed is based and the average cost of lodging incurred during the period covered by this voucher.TRAVELER SIGN HERE
DATE AMOUNT CLAIMED $
NOTE; Falsification of an item in an expense account works a forfeiture of claim (27 U.S.C. 2514) and may result in a fine of not more than $10,000 or imprisonment for not more than 5 years or both (18 U.S.C. 287; i.d. 1001).14. This voucher is approved. Long distance telephone calls, if any, are certified as necessary in the interest of the Government. (NOTE: If long distance telephone calls are included, the approving official must have been authorized in writing by the head of the department or agency to so certify. (31 U.S.C. 680a).
APPROVING OFFICIAL SIGN HERE
DATE
17. FOR FINANCE OFFICE USE ONLY COMPUTATION
a. DIFFER- ENCES, IF ANY (Explain and show amount)
$
15. LAST PRECEDING VOUCHER PAID UNDER SAME TRAVEL AUTHORIZATIONa. VOUCHER NO. b. D.O. SYMBOL c. MONTH &
YEAR
16. THIS VOUCHER IS CERTIFIED CORRECT AND PROPER FOR PAYMENT
AUTHORIZEDCERTIFYING OFFICIAL SIGN HERE
DATE
18. ACCOUNT CLASIFICATION
b. TOTAL VERIFIED CORRECT FOR CHARGE TO APPROPRIATION
c. APPLIED TO TRAVEL ADVANCE (Appropriation symbol):
Certifier's Initials: $
d. NET TO TRAVELER$
$
NSN 7540-00-634-4180 STANDARD FORM 1012 (REV. 10-77) Prescribed by GSA, FPMR (41 CFR) 101-7
Traveler's Initials
5. T
RA
VE
LER
(PA
YE
E)
-
DESCRIPTION (Departure/arrival city, per diem
computation, or other explanations of expense )
SCHEDULE OF EXPENSES AND AMOUNTS CLAIMED
SUBTOTALS
TOTAL AMOUNT CLAIMED
DATE TIME ITEMIZED SUBSISTENCE EXPENSES AMOUNT CLAIMED
Col. (c) If the voucher includes per diem allowances for members of employee's immediate family, show member's names, ages and relationship to em- ployee and marital status of children (unless information is shown on the travel authorization.)
Com- plete only for actual expense travel TRAVELER'S LAST NAME
TRAVEL AUTHORIZATION NO.
Show amount incurred for each meal, including tax and tips, and daily total meal cost.
MEALS
Show expenses, such as: laundry, cleaning and pressing clothes, tips to bellboys, porters, etc. (other than for meals). Complete for per diem and actual expense travel. Show total subsistence expense incurred for actual expense travel. Show per diem amount, limited to maximum rate, or if travel on actual expense, show the lesser of the amount from col. (j) or maximum rate. Show expenses, such as: taxi/limousine fares, air fare (if purchased with cash), local or long distance telephone calls for Government business, car rental, relocation other than subsistence, etc.
(a)
If additional space is required, continue on another SF 1012-A BACK, leaving the front blank.
(c)
INSTRUCTIONS TO TRAVELER (Unlisted items are self-explanation) Complete this information if this is a continuation sheet
Enter grand total of columns (l), (m) and (n), below and in item 13 on the front of this form.
PAGE
of
TOTAL
(g)
(Hour and
am/pm)
(b)
BREAK- FAST
(d)
TOTAL SUBSISTENCE
EXPENSE
(j)
NO. OF MILES
( k)
MILEAGE
(l)
OTHER
(n)
MISCEL- LANEOUS SUBSIS- TENCE
(h)
MILEAGE RATE:
LODGING
(i)
SUBSISTENCE
(m)
In compliance with the Privacy Act of 1974, the following information is provided: Solicitation of the information on this form is authorized by 5 U.S.C. Chap. 57 as implemented by the Federal Travel Regulations (FPMR 101-7), E.O. 11609 of July 22, 1971, E.O. 110012 of March 27, 1962, E.O. 9397 of November 22, 1943, and 26 U.S.C. 6011(b) and 6109. The primary purpose of the requested information is to determine payment or reimbursement to eligible individuals for allowable travel and/or relocation expenses incurred under appropriate administrative authorization and to record and maintain costs of such reimbursements to the Government. The information will be used by officers and employees who have a need for information in the performance of their official duties. The information may be disclosed to appropriate Federal, State, local, or foreign agencies when relevant to civil, criminal or regulatory
investigations or prosecutions, or when pursuant to a requirement by this agency in connection with the hiring or firing of an employee, the issuance of a security clearance, or investigations of the per- formance of official duty while in Government service. Your Social Security Account Number (SSN) is solicited under the authority of the Internal Revenue Code (26 U.S.C. 6011 (b) and 6109) and E.O. 9397, November 22, 1943, for use as a taxpayer and/or employee identification number; disclosure is MANDATORY on vouchers claiming travel and/or relocation allowance expense reimbursement which is, or may be, taxable income. Disclosure of your SSN and other requested information is voluntary in all other instances; however, failure to provide the information (other than SSN) required to support the claim may result in delay or loss of reimbursement.
DINNER
(f)
LUNCH
(e)
STANDARD FORM 1012 BACK (10-77)
(h) (i) (j) (m) (n)
Col. (d) (g) }
TOTALS
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