<table style="width:100%;">
<colgroup>
<col style="width: 3%" />
<col style="width: 0%" />
<col style="width: 5%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 1%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 5%" />
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 5%" />
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 4%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 3%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 6%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 3%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 5%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="9"><strong>TRAVEL VOUCHER</strong></td>
<td colspan="11">1. DEPARTMENT OR</td>
<td colspan="11">2. TYPE OF TRAVEL</td>
<td colspan="9">3. VOUCHER NO.</td>
</tr>
<tr class="even">
<td colspan="9"><em>(Read the Privacy Act</em></td>
<td colspan="11"><blockquote>
<p>BUREAU DIVISION OR OFFICE</p>
</blockquote></td>
<td></td>
<td colspan="10">TEMPORARY DUTY</td>
<td colspan="9"></td>
</tr>
<tr class="odd">
<td colspan="9"><em>Statement on the back)</em></td>
<td colspan="11"></td>
<td></td>
<td colspan="10">PERMANENT CHANGE</td>
<td colspan="9">4. SCHEDULE NO.</td>
</tr>
<tr class="even">
<td colspan="20">5. TRAVELER (PAYEE)</td>
<td></td>
<td colspan="10">OF STATION</td>
<td colspan="9"></td>
</tr>
<tr class="odd">
<td colspan="20">a. NAME <em>(Last, first, middle initial)</em></td>
<td colspan="11">b. SOCIAL SECURITY NO.</td>
<td colspan="9"><strong>6. PERIOD OF TRAVEL</strong></td>
</tr>
<tr class="even">
<td colspan="20"></td>
<td colspan="11"></td>
<td colspan="5">a. FROM</td>
<td colspan="4">b. TO</td>
</tr>
<tr class="odd">
<td colspan="20"></td>
<td colspan="11"></td>
<td colspan="5"></td>
<td colspan="4"></td>
</tr>
<tr class="even">
<td colspan="20">c. MAILING ADDRESS <em>(Include ZIP Code)</em></td>
<td colspan="11">d. OFFICE TELEPHONE NO.</td>
<td colspan="9"><strong>7. TRAVEL AUTHORIZATION</strong></td>
</tr>
<tr class="odd">
<td colspan="20"></td>
<td colspan="11"></td>
<td colspan="5">a. NUMBER(S)</td>
<td colspan="4">b. DATE(S)</td>
</tr>
<tr class="even">
<td colspan="20"></td>
<td colspan="11"></td>
<td colspan="5"></td>
<td colspan="4"></td>
</tr>
<tr class="odd">
<td colspan="17">e. PRESENT DUTY STATION</td>
<td colspan="14">f. RESIDENCE <em>(City and State)</em></td>
<td colspan="5"></td>
<td colspan="4"></td>
</tr>
<tr class="even">
<td colspan="17"></td>
<td colspan="14"></td>
<td colspan="9"><strong>10. CHECK NO.</strong></td>
</tr>
<tr class="odd">
<td colspan="17"></td>
<td colspan="14"></td>
<td colspan="9"></td>
</tr>
<tr class="even">
<td colspan="17"><strong>8. TRAVEL ADVANCE</strong></td>
<td colspan="14"><strong>9. CASH PAYMENT RECEIPT</strong></td>
<td colspan="9"><strong>11. PAID BY</strong></td>
</tr>
<tr class="odd">
<td>a.</td>
<td colspan="10">Outstanding</td>
<td colspan="4"></td>
<td colspan="2"></td>
<td colspan="6">a. DATE RECEIVED</td>
<td colspan="8">b. AMOUNT RECEIVED</td>
<td colspan="9"></td>
</tr>
<tr class="even">
<td>b.</td>
<td colspan="10">Amount to be applied</td>
<td colspan="4"></td>
<td colspan="2"></td>
<td colspan="6"></td>
<td>$</td>
<td colspan="7"></td>
<td colspan="9"></td>
</tr>
<tr class="odd">
<td>c.</td>
<td colspan="10">Amount due Government</td>
<td colspan="4"></td>
<td colspan="2"></td>
<td colspan="14">c. PAYEE’S SIGNATURE</td>
<td colspan="9"></td>
</tr>
<tr class="even">
<td></td>
<td colspan="3">Attached:</td>
<td colspan="2"></td>
<td colspan="2"><em>Check</em></td>
<td></td>
<td colspan="2"><em>Cash</em></td>
<td colspan="4"></td>
<td colspan="2"></td>
<td colspan="14"></td>
<td colspan="9"></td>
</tr>
<tr class="odd">
<td>d.</td>
<td colspan="10">Balance outstanding</td>
<td colspan="4"></td>
<td colspan="2"></td>
<td colspan="14"></td>
<td colspan="9"></td>
</tr>
<tr class="even">
<td colspan="2">12.</td>
<td colspan="8"><p>GOVERNMENT TRANSPORATION REQUESTS, OR</p>
<p>TRANSPORTATION</p></td>
<td colspan="24">I hereby assign to the United States any right I may
have against any parties in connection with reimbursable transporation
chrages described below, purchased under cash payment procedures (FPMR
101-7)</td>
<td colspan="4">Traveler’s Initials</td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="8"><p>TICKETS, IF PURCHASED</p>
<p>WITH CASH (List by number below and attach passenger coupon; if cash
is used show claim on reverse side.)</p></td>
<td colspan="4"><p>AGENT’S VALUATION OF TICKET</p>
<p>(a)</p></td>
<td colspan="4"><p>ISSUING CARRIER</p>
<p>(Initials)</p>
<p>(b)</p></td>
<td colspan="8">MODE, CLASS OF SERVICE AND ACCOMMODATIONS (c)</td>
<td colspan="5"><p>DATE</p>
<p>ISSUED</p>
<p>(d)</p></td>
<td colspan="9"><p><strong>POINTS OF TRAVEL</strong></p>
<p>FROM TO</p>
<p>(e) (f)</p></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="8"></td>
<td colspan="4"></td>
<td colspan="4"></td>
<td colspan="8"></td>
<td colspan="5"></td>
<td colspan="4"></td>
<td colspan="5"></td>
</tr>
<tr class="odd">
<td colspan="2">13.</td>
<td colspan="31">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 on the
average cost of lodging incurred during the period covered by this
voucher.</td>
<td colspan="6"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="3"><p>TRAVELER</p>
<p>SIGN HERE</p></td>
<td colspan="19"></td>
<td colspan="6"><strong>DATE</strong></td>
<td colspan="2"></td>
<td colspan="3"><p><strong>AMOUNT</strong></p>
<p><strong>CLAIMED</strong></p></td>
<td colspan="2">$</td>
<td colspan="4"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="33"><em>NOTE: Falsification of an item in an expense
account works a forfeiture of claim (28 U.S.C. 2514) and may result in a
fine of not more than $10,000 or imprisonment for not more than 5 years
or both (18 U.S.C. 287; i.d. 1001).</em></td>
<td colspan="7"></td>
</tr>
<tr class="even">
<td colspan="2">14.</td>
<td colspan="17">This voucher is approved. Long distance telephone
calls, if any, are certified as necessary in the interest of the
Government. <em>(NOTE: If long</em></td>
<td colspan="13"><ol start="17" type="1">
<li><p><em><strong>FOR FINANCE OFFICE USE ONLY</strong></em></p></li>
</ol>
<blockquote>
<p><em><strong>COMPUTATION</strong></em></p>
</blockquote></td>
<td colspan="5"></td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="17"><em>distance telephone calls are included, the
approving official must have been</em></td>
<td colspan="8">a. DIFFER-</td>
<td colspan="5"></td>
<td>$</td>
<td colspan="4"></td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="17"><em>authorized in writing by the head of the department
or agency to so certify</em></td>
<td colspan="8"><blockquote>
<p>ENCES,</p>
</blockquote></td>
<td colspan="5"></td>
<td colspan="5"></td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="17"><em>(31 U.S.C. 680a).)</em></td>
<td colspan="8"><blockquote>
<p>IF ANY</p>
</blockquote></td>
<td colspan="5"></td>
<td colspan="5"></td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td colspan="13"></td>
<td colspan="6"></td>
<td colspan="8"><blockquote>
<p><em>(Explain</em></p>
</blockquote></td>
<td colspan="5"></td>
<td colspan="5"></td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td colspan="13"><strong>APPROVING</strong></td>
<td colspan="6"><strong>DATE</strong></td>
<td colspan="8"><blockquote>
<p><em>and show</em></p>
</blockquote></td>
<td colspan="5"></td>
<td colspan="5"></td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td colspan="13"><strong>OFFICIAL</strong></td>
<td colspan="6"></td>
<td colspan="8"><blockquote>
<p><em>amount)</em></p>
</blockquote></td>
<td colspan="5"></td>
<td colspan="5"></td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td colspan="13"><strong>SIGN HERE</strong></td>
<td colspan="6"></td>
<td colspan="8"></td>
<td colspan="5"></td>
<td colspan="5"></td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td colspan="19"><strong>15. LAST PRECEDING VOUCHER PAID UNDER SAME
TRAVEL AUTHORIZATION</strong></td>
<td colspan="13"><ol start="2" type="a">
<li><p>TOTAL VERIFIED CORRECT FOR</p></li>
</ol>
<blockquote>
<p>CHARGE TO APPROPRIATION</p>
</blockquote></td>
<td colspan="5"></td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td colspan="7">a. VOUCHER NO.</td>
<td colspan="5">b. D.O. SYMBOL</td>
<td colspan="7">c. MONTH &amp; YEAR</td>
<td colspan="13"></td>
<td colspan="5"></td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td colspan="7"></td>
<td colspan="5"></td>
<td colspan="7"></td>
<td colspan="10"></td>
<td colspan="3"></td>
<td></td>
<td colspan="4"></td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td colspan="7"></td>
<td colspan="5"></td>
<td colspan="7"></td>
<td colspan="10"><blockquote>
<p><em>Certifier’s initials:</em></p>
</blockquote></td>
<td colspan="3"></td>
<td>$</td>
<td colspan="4"></td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td colspan="19"><strong>16. THIS VOUCHER IS CERTIFIED CORRECT AND
PROPER FOR PAYMENT</strong></td>
<td colspan="13">c. APPLIED TO TRAVEL ADVANCE</td>
<td colspan="5"></td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td colspan="19"></td>
<td colspan="13"><blockquote>
<p><em>(Appropriation symbol):</em></p>
</blockquote></td>
<td>$</td>
<td colspan="4"></td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td colspan="5"><p>AUTHORIZED</p>
<p>CERTIFIYING</p>
<p>OFFICIAL</p>
<p>SIGN HERE</p></td>
<td colspan="7"></td>
<td colspan="4">DATE</td>
<td colspan="3"></td>
<td colspan="6">d.</td>
<td colspan="7"><strong>NET TO TRAVELER</strong></td>
<td>$</td>
<td colspan="4"></td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td colspan="40"><strong>18. ACCOUNTING CLASSIFICATION</strong></td>
</tr>
<tr class="even">
<td colspan="40"></td>
</tr>
<tr class="odd">
<td colspan="40">Standard Form 1012 (Rev Oct 77) (MS Word Sep 97)</td>
</tr>
</tbody>
</table>

<table>
<colgroup>
<col style="width: 3%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 2%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 1%" />
<col style="width: 4%" />
<col style="width: 3%" />
<col style="width: 4%" />
<col style="width: 3%" />
<col style="width: 0%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 1%" />
<col style="width: 3%" />
<col style="width: 0%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 3%" />
<col style="width: 0%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 2%" />
<col style="width: 3%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 5%" />
<col style="width: 3%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 3%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 1%" />
<col style="width: 2%" />
<col style="width: 2%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="61"><strong>SCHEDULE OF EXPENSES AND AMOUNTS
CLAIMED</strong></td>
</tr>
<tr class="even">
<td colspan="49">INSTRUCTIONS TO TRAVELER (Unlisted items are
self-explanatory)</td>
<td colspan="4">Complete this information if this</td>
<td colspan="6">PAGE</td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="49">Col. (c)</td>
<td colspan="4">is a continuation</td>
<td colspan="6">OF</td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="49"></td>
<td colspan="4">sheet</td>
<td colspan="6"></td>
<td colspan="2">PAGES</td>
</tr>
<tr class="odd">
<td colspan="11">If the voucher includes per diem allowances for members
of employee’s immediate family, show members’ names, ages, and
relationship to employee and marital</td>
<td colspan="2"><p>Com-</p>
<p>plete</p>
<p>only</p>
<p>for actual</p>
<p>expense</p>
<p>travel</p></td>
<td><p>Col.</p>
<p>thru</p></td>
<td colspan="2"><p>(d)</p>
<p>(g)</p>
<p>(h)</p>
<p>(i)</p></td>
<td colspan="33"><p>Show amount incurred for each meal, including tax
and tips, and daily total</p>
<p>meal cost</p>
<p>Show expenses, such as: laundry, cleaning and pressing of clothes,
tips to bellboys, porters, etc. (other than for meals).</p>
<p>Complete for per diem and acutal expense travel.</p></td>
<td colspan="6"><p><strong>TRAVEL</strong></p>
<p><strong>AUTHORIZATION</strong></p>
<p><strong>NO.</strong></p></td>
<td colspan="6"></td>
</tr>
<tr class="even">
<td colspan="11">status of children (unless information is shown on the
travel authorization.)</td>
<td colspan="2"></td>
<td></td>
<td colspan="2"><p>(j)</p>
<p>(m)</p>
<p>(n)</p></td>
<td colspan="33"><p>Show total subsistence expense incurred for actual
expense travel</p>
<p>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.</p>
<p>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.</p></td>
<td colspan="6"><p><strong>TRAVELER’S</strong></p>
<p><strong>LAST</strong></p>
<p><strong>NAME</strong></p></td>
<td colspan="6"></td>
</tr>
<tr class="odd">
<td colspan="3"><strong>DATE</strong></td>
<td colspan="4"><strong>TIME</strong></td>
<td colspan="7">DESCRIPTION</td>
<td colspan="32">ITEMIZIED SUBSISTENCE EXPENSES</td>
<td colspan="3"><p>MILEAGE</p>
<p>RATE:</p></td>
<td colspan="12"><strong>AMOUNT CLAIMED</strong></td>
</tr>
<tr class="even">
<td><strong>19</strong></td>
<td colspan="2"></td>
<td colspan="4"><em>(Hour</em></td>
<td colspan="7"><em>(Departure/arrival city, per diem</em></td>
<td colspan="19">MEALS</td>
<td colspan="4">MISC.</td>
<td colspan="4"></td>
<td colspan="5">TOTAL</td>
<td colspan="3">.30</td>
<td colspan="2">MILEAGE</td>
<td colspan="6">SUBSISTENCE</td>
<td colspan="4">OTHER</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="2"></td>
<td colspan="4"><em>and</em></td>
<td colspan="7"><em>computation, or other</em></td>
<td colspan="4">BREAK-</td>
<td colspan="3"></td>
<td colspan="8"></td>
<td colspan="4"></td>
<td colspan="4">SUBSIS-</td>
<td colspan="4"></td>
<td colspan="5">SUBSISTENCE</td>
<td colspan="3">NO. OF</td>
<td colspan="2"></td>
<td colspan="6"></td>
<td colspan="4"></td>
</tr>
<tr class="even">
<td></td>
<td colspan="2"></td>
<td colspan="4"><em>am/pm</em></td>
<td colspan="7"><em>explanations of expense)</em></td>
<td colspan="4">FAST</td>
<td colspan="3">LUNCH</td>
<td colspan="8">DINNER</td>
<td colspan="4">TOTAL</td>
<td colspan="4">TENCE</td>
<td colspan="4">LODGING</td>
<td colspan="5">EXPENSE</td>
<td colspan="3">MILES</td>
<td colspan="2"></td>
<td colspan="6"></td>
<td colspan="4"></td>
</tr>
<tr class="odd">
<td colspan="3"><strong>(a)</strong></td>
<td colspan="4"><strong>(b)</strong></td>
<td colspan="7">(c)</td>
<td colspan="4">(d)</td>
<td colspan="3">(e)</td>
<td colspan="8">(f)</td>
<td colspan="4">(g)</td>
<td colspan="4">(h)</td>
<td colspan="4">(i)</td>
<td colspan="5">(j)</td>
<td colspan="3">(k)</td>
<td colspan="2">(l)</td>
<td colspan="6">(m)</td>
<td colspan="4">(n)</td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="4"></td>
<td colspan="7"></td>
<td></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="4"></td>
<td colspan="3"></td>
<td></td>
<td colspan="3"></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="4"></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="4"></td>
<td colspan="7"></td>
<td></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="4"></td>
<td colspan="3"></td>
<td></td>
<td colspan="3"></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="4"></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="4"></td>
<td colspan="7"></td>
<td></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="4"></td>
<td colspan="3"></td>
<td></td>
<td colspan="3"></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="4"></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="4"></td>
<td colspan="7"></td>
<td></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="4"></td>
<td colspan="3"></td>
<td></td>
<td colspan="3"></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="4"></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="4"></td>
<td colspan="7"></td>
<td></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="4"></td>
<td colspan="3"></td>
<td></td>
<td colspan="3"></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="4"></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="4"></td>
<td colspan="7"></td>
<td></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="4"></td>
<td colspan="3"></td>
<td></td>
<td colspan="3"></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="4"></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="4"></td>
<td colspan="7"></td>
<td></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="4"></td>
<td colspan="3"></td>
<td></td>
<td colspan="3"></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="4"></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="4"></td>
<td colspan="7"></td>
<td></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="4"></td>
<td colspan="3"></td>
<td></td>
<td colspan="3"></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="4"></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="4"></td>
<td colspan="7"></td>
<td></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="4"></td>
<td colspan="3"></td>
<td></td>
<td colspan="3"></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="4"></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="4"></td>
<td colspan="7"></td>
<td></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="4"></td>
<td colspan="3"></td>
<td></td>
<td colspan="3"></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="4"></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="4"></td>
<td colspan="7"></td>
<td></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="4"></td>
<td colspan="3"></td>
<td></td>
<td colspan="3"></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="4"></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="5">Traveler took</td>
<td colspan="4"></td>
<td colspan="8">days leave.</td>
<td colspan="14">ATM Advance Fees: ($</td>
<td colspan="3"></td>
<td colspan="9">plus any surcharge x .0275 = ($</td>
<td colspan="4"></td>
<td colspan="2">)</td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="4"></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="2">Traveler</td>
<td colspan="2"></td>
<td colspan="2">did</td>
<td colspan="2"></td>
<td colspan="9">did not use the rental car authorized.</td>
<td colspan="10">Receipts Attached:</td>
<td colspan="3"></td>
<td colspan="4">Lodging</td>
<td></td>
<td colspan="3">Other</td>
<td colspan="4"></td>
<td colspan="7"></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="4"></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="10">Of the total miles reported,</td>
<td colspan="2"></td>
<td colspan="7">miles were for personal use.</td>
<td colspan="7"></td>
<td colspan="2"></td>
<td colspan="5"></td>
<td colspan="2"></td>
<td colspan="5"></td>
<td></td>
<td colspan="4"></td>
<td colspan="4"></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="4"></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="41"></td>
<td colspan="7">SUBTOTALS</td>
<td></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="4"></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="41"><em>If additional space is required, continue on
another SF 1012-A BACK, leaving the front blank.</em></td>
<td colspan="7"><em>TOTALS</em></td>
<td></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="4"></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="23">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. 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 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 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</td>
<td></td>
<td colspan="25">agency in connection with the hiring or firing of an
employee, the issuance of a security clearance, orinvestigations 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 6109) and E.O. 9397,
November 22, 1943, for use as a tax payer and/or employee identification
number; disclosure is MANDATORY on vouches 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.</td>
<td colspan="7"><p><em>Enter grand total of columns (l), (m), and (n),
below and in item 13 on the front of this form.</em></p>
<p><strong>TOTAL</strong></p>
<p><strong>AMOUNT</strong></p>
<p><strong>CLAIMED</strong></p></td>
<td colspan="5"></td>
</tr>
<tr class="odd">
<td colspan="61">Standard Form 1012A (Oct 77) (MS Word Oct 97)</td>
</tr>
</tbody>
</table>