<table style="width:100%;">
<colgroup>
<col style="width: 3%" />
<col style="width: 5%" />
<col style="width: 2%" />
<col style="width: 17%" />
<col style="width: 1%" />
<col style="width: 7%" />
<col style="width: 1%" />
<col style="width: 10%" />
<col style="width: 10%" />
<col style="width: 10%" />
<col style="width: 9%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 9%" />
<col style="width: 9%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="4" rowspan="2"><p><strong>CLAIM FOR
REIMBURSEMENT</strong></p>
<p><strong>FOR EXPENDITURES ON</strong></p>
<p><strong>OFFICIAL BUSNIESS</strong></p></td>
<td colspan="9" rowspan="2"><p>1. DEPARTMENT OR ESTABLISHMENT, BUREAU,
DIVISION OR OFFICE</p>
<p>     </p></td>
<td colspan="2"><p>2. VOUCHER NUMBER</p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="2"><p>3. SCHEDULE NUMBER</p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="15"><em>Read the Privacy Act Statement on second
page</em></td>
</tr>
<tr class="even">
<td><strong>4</strong></td>
<td colspan="6" rowspan="2"><ol type="a">
<li><p>Name (Last, first, middle initial)</p></li>
</ol>
<p>     </p></td>
<td colspan="5" rowspan="2"><ol start="2" type="a">
<li><p>Social Security NO.</p></li>
</ol>
<p>     </p></td>
<td colspan="3" rowspan="3"><p><strong>5. PAID BY</strong></p>
<p>     </p></td>
</tr>
<tr class="odd">
<td rowspan="2"><blockquote>
<p><strong>CLAIMANT</strong></p>
</blockquote></td>
</tr>
<tr class="even">
<td colspan="6"><ol start="3" type="a">
<li><p>Mailing Address (Include ZIP Code)</p></li>
</ol>
<p>     </p></td>
<td colspan="5"><ol start="4" type="a">
<li><p>Office Telephone Number</p></li>
</ol>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="15"><strong>6. EXPENDITURES</strong> <em>( If fare claimed
in col. (g) exceeds charge for one person, show in col. (h) the number
of additional persons which accompanied the claimant.)</em></td>
</tr>
<tr class="even">
<td colspan="2" rowspan="6"><p>DATE</p>
<p>19<u>99</u></p>
<p>(a)</p></td>
<td rowspan="6"></td>
<td colspan="5" rowspan="4"><p><em>Show Appropriate code in col.
(b):</em></p>
<p>C</p>
<p>O <strong>A</strong>- Local travel</p>
<p>D <strong>B</strong>-Telephone or telegraph, or</p>
<p>E <strong>C</strong>-Other Expenses (itemized)</p></td>
<td rowspan="4"><p>Mileage</p>
<p>Rate</p>
<p>      ¢</p></td>
<td colspan="6"><strong>AMOUNT CLAIMED</strong></td>
</tr>
<tr class="odd">
<td rowspan="5"><p>MILEAGE</p>
<p>(f)</p></td>
<td rowspan="5"><p>FARE<br />
OR TOLL</p>
<p>(g)</p></td>
<td colspan="3" rowspan="5"><p>ADD</p>
<p>PERSONS</p>
<p>(h)</p></td>
<td rowspan="5"><p>TIPS, AND</p>
<p>MISCELLA-</p>
<p>NEOUS</p>
<p>(i)</p></td>
</tr>
<tr class="even">
</tr>
<tr class="odd">
</tr>
<tr class="even">
<td colspan="5">(Explain expenditures in specific detail.)</td>
<td rowspan="2"><p>No. of</p>
<p>Miles (e)</p></td>
</tr>
<tr class="odd">
<td colspan="2">( c ) FROM</td>
<td colspan="3">(d) TO</td>
</tr>
<tr class="even">
<td colspan="2">     </td>
<td rowspan="2"></td>
<td colspan="2" rowspan="2">     </td>
<td colspan="3" rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">0.00</td>
<td rowspan="2">     </td>
<td colspan="3" rowspan="2">     </td>
<td rowspan="2">     </td>
</tr>
<tr class="odd">
<td colspan="2">     </td>
</tr>
<tr class="even">
<td colspan="2">     </td>
<td rowspan="2"></td>
<td colspan="2" rowspan="2">     </td>
<td colspan="3" rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">0.00</td>
<td rowspan="2">     </td>
<td colspan="3" rowspan="2">     </td>
<td rowspan="2">     </td>
</tr>
<tr class="odd">
<td colspan="2">     </td>
</tr>
<tr class="even">
<td colspan="2">     </td>
<td rowspan="2"></td>
<td colspan="2" rowspan="2">     </td>
<td colspan="3" rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">0.00</td>
<td rowspan="2">     </td>
<td colspan="3" rowspan="2">     </td>
<td rowspan="2">     </td>
</tr>
<tr class="odd">
<td colspan="2">     </td>
</tr>
<tr class="even">
<td colspan="2">     </td>
<td rowspan="2"></td>
<td colspan="2" rowspan="2">     </td>
<td colspan="3" rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">0.00</td>
<td rowspan="2">     </td>
<td colspan="3" rowspan="2">     </td>
<td rowspan="2">     </td>
</tr>
<tr class="odd">
<td colspan="2">     </td>
</tr>
<tr class="even">
<td colspan="2">     </td>
<td rowspan="2"></td>
<td colspan="2" rowspan="2">     </td>
<td colspan="3" rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">0.00</td>
<td rowspan="2">     </td>
<td colspan="3" rowspan="2">     </td>
<td rowspan="2">     </td>
</tr>
<tr class="odd">
<td colspan="2">     </td>
</tr>
<tr class="even">
<td colspan="2">     </td>
<td rowspan="2"></td>
<td colspan="2" rowspan="2">     </td>
<td colspan="3" rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">0.00</td>
<td rowspan="2">     </td>
<td colspan="3" rowspan="2">     </td>
<td rowspan="2">     </td>
</tr>
<tr class="odd">
<td colspan="2">     </td>
</tr>
<tr class="even">
<td colspan="2">     </td>
<td rowspan="2"></td>
<td colspan="2" rowspan="2">     </td>
<td colspan="3" rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">0.00</td>
<td rowspan="2">     </td>
<td colspan="3" rowspan="2">     </td>
<td rowspan="2">     </td>
</tr>
<tr class="odd">
<td colspan="2">     </td>
</tr>
<tr class="even">
<td colspan="2">     </td>
<td></td>
<td colspan="2" rowspan="2">     </td>
<td colspan="3" rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">0.00</td>
<td rowspan="2">     </td>
<td colspan="3" rowspan="2">     </td>
<td rowspan="2">     </td>
</tr>
<tr class="odd">
<td colspan="2">     </td>
<td></td>
</tr>
<tr class="even">
<td colspan="2">     </td>
<td rowspan="2"></td>
<td colspan="2" rowspan="2">     </td>
<td colspan="3" rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">0.00</td>
<td rowspan="2">     </td>
<td colspan="3" rowspan="2">     </td>
<td rowspan="2">     </td>
</tr>
<tr class="odd">
<td colspan="2">     </td>
</tr>
<tr class="even">
<td colspan="6">If additional space is required continue on the next
page</td>
<td colspan="2">Subtotals carried forward from the next page</td>
<td>     </td>
<td>     </td>
<td>     </td>
<td colspan="3">     </td>
<td>     </td>
</tr>
<tr class="odd">
<td colspan="6"><strong>7. AMOUNT CLAIMED (</strong>Total of col.s. (f),
(g) and (i)      </td>
<td colspan="2"><h1 id="totals">TOTALS</h1></td>
<td>     </td>
<td>     </td>
<td>     </td>
<td colspan="3">     </td>
<td>     </td>
</tr>
<tr class="even">
<td colspan="8" rowspan="2"><p>8. This claim is approved. Long distance
telephone calls, if shown, are certified as necessary in the interest of
the Government. (Note: if long distance 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).)</p>
<h2 id="sign-original-only"> Sign Original Only</h2>
<p><strong>APPROVING</strong></p>
<p><strong>OFFICIAL</strong></p>
<p><strong>SIGN HERE</strong> Date      </p></td>
<td colspan="7"><ol start="10" type="1">
<li><p>I certify that this claim is true and correct to the best of my
knowledge and belief and that payment or credit has not been received by
me.</p></li>
</ol>
<p><em>SIGN ORIGINAL ONLY</em></p>
<p><strong>CLAIMANT</strong></p>
<p><strong>SIGN HERE =&gt;</strong> Date      </p></td>
</tr>
<tr class="odd">
<td colspan="7">11. <strong>CASH PAYMENT RECEIPT</strong></td>
</tr>
<tr class="even">
<td colspan="8" rowspan="3"><p><strong>9.</strong> This claim is
certified correct and proper for payment</p>
<p><em>Sign Original Only</em></p>
<p>AUTHORIZED</p>
<p>CERTIFING</p>
<p>SIGN HERE Date      </p></td>
<td colspan="4" rowspan="2">a. PAYEE (Signature)</td>
<td colspan="3"><p>b. Date Received</p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="3"><p>c. Amount</p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="7"><p>12. Payment made</p>
<blockquote>
<p>By Check No.      </p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="15"><p>ACCOUNTING CLASSIFICATION</p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="8">1164-210</td>
<td colspan="7"><p>STANDARD FORM 1164 ( Rev. 11-77)</p>
<p>Prescribed by GSA, FPMR (CFR 41) 101-7</p></td>
</tr>
</tbody>
</table>

6\. EXPENDITURES - Continued

<table style="width:100%;">
<colgroup>
<col style="width: 9%" />
<col style="width: 2%" />
<col style="width: 19%" />
<col style="width: 19%" />
<col style="width: 9%" />
<col style="width: 9%" />
<col style="width: 0%" />
<col style="width: 9%" />
<col style="width: 9%" />
<col style="width: 9%" />
<col style="width: 0%" />
</colgroup>
<tbody>
<tr class="odd">
<td rowspan="4"><p>DATE</p>
<p>19<u>99</u></p>
<p>(a)</p></td>
<td colspan="3" rowspan="2"><p>Show appropriate code in col. (b)</p>
<p>C</p>
<p>O <strong>A</strong>- Local travel</p>
<p>D <strong>B</strong>- Telephone or telegraph, or</p>
<p>E <strong>C</strong> - Other Expenses <em>(itemized)</em></p></td>
<td rowspan="2"><p>Mileage</p>
<p>Rate</p>
<p>0.000</p></td>
<td colspan="6"><strong>AMOUNT CLAIMED</strong></td>
</tr>
<tr class="even">
<td rowspan="3"><p>MILEAGE</p>
<p>(f)</p></td>
<td colspan="2" rowspan="3"><p>FARE<br />
OR TOLL</p>
<p>(g)</p></td>
<td rowspan="3"><p>ADD</p>
<p>PERSONS</p>
<p>(h)</p></td>
<td colspan="2" rowspan="3"><p>TIPS, AND</p>
<p>MISCELLA-</p>
<p>NEOUS</p>
<p>(i)</p></td>
</tr>
<tr class="odd">
<td rowspan="2"></td>
<td colspan="2"><em>(Explain expenditures in specific detail.)</em></td>
<td rowspan="2"><p>No. of</p>
<p>Miles</p>
<p>(e)</p></td>
</tr>
<tr class="even">
<td>( c ) FROM</td>
<td>(d) TO</td>
</tr>
<tr class="odd">
<td>     </td>
<td rowspan="2"></td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">0.00</td>
<td colspan="2" rowspan="2">     </td>
<td rowspan="2">     </td>
<td colspan="2" rowspan="2">     </td>
</tr>
<tr class="even">
<td>     </td>
</tr>
<tr class="odd">
<td>     </td>
<td rowspan="2"></td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">0.00</td>
<td colspan="2" rowspan="2">     </td>
<td rowspan="2">     </td>
<td colspan="2" rowspan="2">     </td>
</tr>
<tr class="even">
<td>     </td>
</tr>
<tr class="odd">
<td>     </td>
<td rowspan="2"></td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">0.00</td>
<td colspan="2" rowspan="2">     </td>
<td rowspan="2">     </td>
<td colspan="2" rowspan="2">     </td>
</tr>
<tr class="even">
<td>     </td>
</tr>
<tr class="odd">
<td>     </td>
<td rowspan="2"></td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">0.00</td>
<td colspan="2" rowspan="2">     </td>
<td rowspan="2">     </td>
<td colspan="2" rowspan="2">     </td>
</tr>
<tr class="even">
<td>     </td>
</tr>
<tr class="odd">
<td>     </td>
<td rowspan="2"></td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">0.00</td>
<td colspan="2" rowspan="2">     </td>
<td rowspan="2">     </td>
<td colspan="2" rowspan="2">     </td>
</tr>
<tr class="even">
<td>     </td>
</tr>
<tr class="odd">
<td>     </td>
<td rowspan="2"></td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">0.00</td>
<td colspan="2" rowspan="2">     </td>
<td rowspan="2">     </td>
<td colspan="2" rowspan="2">     </td>
</tr>
<tr class="even">
<td>     </td>
</tr>
<tr class="odd">
<td>     </td>
<td rowspan="2"></td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">0.00</td>
<td colspan="2" rowspan="2">     </td>
<td rowspan="2">     </td>
<td colspan="2" rowspan="2">     </td>
</tr>
<tr class="even">
<td>     </td>
</tr>
<tr class="odd">
<td>     </td>
<td rowspan="2"></td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">0.00</td>
<td colspan="2" rowspan="2">     </td>
<td rowspan="2">     </td>
<td colspan="2" rowspan="2">     </td>
</tr>
<tr class="even">
<td>     </td>
</tr>
<tr class="odd">
<td>     </td>
<td rowspan="2"></td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">0.00</td>
<td colspan="2" rowspan="2">     </td>
<td rowspan="2">     </td>
<td colspan="2" rowspan="2">     </td>
</tr>
<tr class="even">
<td>     </td>
</tr>
<tr class="odd">
<td>     </td>
<td rowspan="2"></td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">0.00</td>
<td colspan="2" rowspan="2">     </td>
<td rowspan="2">     </td>
<td colspan="2" rowspan="2">     </td>
</tr>
<tr class="even">
<td>     </td>
</tr>
<tr class="odd">
<td>     </td>
<td rowspan="2"></td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">0.00</td>
<td colspan="2" rowspan="2">     </td>
<td rowspan="2">     </td>
<td colspan="2" rowspan="2">     </td>
</tr>
<tr class="even">
<td>     </td>
</tr>
<tr class="odd">
<td>     </td>
<td rowspan="2"></td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">0.00</td>
<td colspan="2" rowspan="2">     </td>
<td rowspan="2">     </td>
<td colspan="2" rowspan="2">     </td>
</tr>
<tr class="even">
<td>     </td>
</tr>
<tr class="odd">
<td>     </td>
<td rowspan="2"></td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">0.00</td>
<td colspan="2" rowspan="2">     </td>
<td rowspan="2">     </td>
<td colspan="2" rowspan="2"><strong>     </strong></td>
</tr>
<tr class="even">
<td>     </td>
</tr>
<tr class="odd">
<td colspan="4">Total each column and enter on the front, subtotal line
=&gt;</td>
<td>     </td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
<td colspan="2">     </td>
</tr>
<tr class="even">
<td colspan="11">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. Chapter 57 as implemented by the
Federal Travel Regulation’s (FPMR 101-7), E.O. 11609 of July 22, 1971,
E.O. 11012 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 in reimbursement to eligible individuals for
allowable travel and/or other expenses incurred under appropriate
administrative authorization and to record and maintain costs of such
reimbursements to the Government. The information will be used by
Federal agency officers and employees who have a need for the
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 on
connection with hiring or firing of an employee, the issuance of a
security clearance or investigations of the performance 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 E.O. 9397, November 22, 1943, for use as a taxpayer
and/or employee identification number; disclosure is MANDATORY on
vouchers claiming payment or reimbursement which is, or may be, taxable
income. Disclosure of your SSN and other requested information is
voluntary in all other instance; however, failure to provide the
information (other than SSN) required to support the claim may results
in delay or loss of reimbursement.</td>
</tr>
<tr class="odd">
<td colspan="10"><strong>U.S. Government Printing Office: 1995 STANDARD
FORM 1164 Back (Rev.11-77)</strong></td>
<td></td>
</tr>
</tbody>
</table>