<table>
<colgroup>
<col style="width: 3%" />
<col style="width: 0%" />
<col style="width: 2%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 2%" />
<col style="width: 18%" />
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 1%" />
<col style="width: 12%" />
<col style="width: 2%" />
<col style="width: 6%" />
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 4%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 3%" />
<col style="width: 2%" />
<col style="width: 3%" />
<col style="width: 5%" />
<col style="width: 3%" />
<col style="width: 4%" />
<col style="width: 6%" />
<col style="width: 3%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="7" rowspan="4"><h1 id="claim-for-reimbursement">CLAIM FOR
REIMBURSEMENT</h1>
<p><strong>FOR EXPENDITURES</strong></p>
<p><strong>ON OFFICIAL BUSINESS</strong></p></td>
<td colspan="11"><p>1. DEPARTMENT OR ESTABLISHMENT, BUREAU, DIVISION
OR</p>
<p>OFFICE</p></td>
<td colspan="8">2. VOUCHER NUMBER</td>
</tr>
<tr class="even">
<td colspan="11" rowspan="3">     </td>
<td colspan="8">     </td>
</tr>
<tr class="odd">
<td colspan="8">3. SCHEDULE NUMBER</td>
</tr>
<tr class="even">
<td colspan="8">     </td>
</tr>
<tr class="odd">
<td colspan="18"><em>Read the Privacy Act Statement on the back of this
form.</em></td>
<td colspan="8"><strong>5. PAID BY</strong></td>
</tr>
<tr class="even">
<td rowspan="4"><blockquote>
<p><strong>4. CLAIMANT</strong></p>
</blockquote></td>
<td colspan="10">a. NAME <em>(Last, first, middle initial)</em></td>
<td colspan="7">b. SOCIAL SECURITY NUMBER</td>
<td colspan="8" rowspan="4">     </td>
</tr>
<tr class="odd">
<td colspan="10">     </td>
<td colspan="7">   -  -    </td>
</tr>
<tr class="even">
<td colspan="10" rowspan="2"><p>c. MAILING ADDRESS <em>(Include ZIP
Code)</em></p>
<p>     </p></td>
<td colspan="7"><p>d. OFFICE TELEPHONE</p>
<p>NUMBER</p></td>
</tr>
<tr class="odd">
<td colspan="7">     </td>
</tr>
<tr class="even">
<td colspan="26"><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="odd">
<td colspan="4" rowspan="2">DATE</td>
<td colspan="2" rowspan="4"><p>C</p>
<p>O</p>
<p>D</p>
<p>E</p></td>
<td colspan="9" rowspan="3"><p><em>Show appropriate code in col.
(b):</em></p>
<p><strong>A -</strong> Local travel</p>
<p><strong>B</strong> – Telephone or telegraph, or</p>
<p><strong>C</strong> – Other Expenses <em>(itemized)</em></p></td>
<td colspan="2" rowspan="2"><p>MILEAGE</p>
<p>RATE</p></td>
<td colspan="9"><h2 id="amount-claimed">AMOUNT CLAIMED</h2></td>
</tr>
<tr class="even">
<td colspan="4" rowspan="3">MILEAGE</td>
<td colspan="2" rowspan="3"><p>FARE</p>
<p>OR TOLL</p></td>
<td rowspan="3"><p>ADD.</p>
<p>PER-</p>
<p>SONS</p></td>
<td colspan="2" rowspan="3"><p>TIPS AND</p>
<p>MISCEL-</p>
<p>LANEOUS</p></td>
</tr>
<tr class="odd">
<td colspan="2">20</td>
<td>  </td>
<td></td>
<td colspan="2">    </td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="9"><em>(Explain expenditures in specific detail.)</em></td>
<td colspan="2" rowspan="2"><p>NO. OF</p>
<p>MILES</p>
<p><em>(e)</em></p></td>
</tr>
<tr class="odd">
<td colspan="4"><em>(a)</em></td>
<td colspan="2"><em>(b)</em></td>
<td colspan="4"><em>(c)</em> FROM</td>
<td colspan="5"><em>(d</em>) TO</td>
<td colspan="4"><em>(f)</em></td>
<td colspan="2"><em>(g)</em></td>
<td><em>(h)</em></td>
<td colspan="2"><em>(i)</em></td>
</tr>
<tr class="even">
<td colspan="4">     </td>
<td colspan="2" rowspan="2"> </td>
<td colspan="4" rowspan="2">     </td>
<td colspan="5" rowspan="2">     </td>
<td colspan="2" rowspan="2">     </td>
<td colspan="3" rowspan="2">     </td>
<td rowspan="2">  </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
<td rowspan="2">  </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
</tr>
<tr class="odd">
<td colspan="4">     </td>
</tr>
<tr class="even">
<td colspan="4">     </td>
<td colspan="2" rowspan="2"> </td>
<td colspan="4" rowspan="2">     </td>
<td colspan="5" rowspan="2">     </td>
<td colspan="2" rowspan="2">     </td>
<td colspan="3" rowspan="2">     </td>
<td rowspan="2">  </td>
<td rowspan="2">     </td>
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<td rowspan="2">  </td>
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<td rowspan="2">  </td>
</tr>
<tr class="odd">
<td colspan="4">     </td>
</tr>
<tr class="even">
<td colspan="4">     </td>
<td colspan="2" rowspan="2"> </td>
<td colspan="4" rowspan="2">     </td>
<td colspan="5" rowspan="2">     </td>
<td colspan="2" rowspan="2">     </td>
<td colspan="3" rowspan="2">     </td>
<td rowspan="2">  </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
<td rowspan="2">  </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
</tr>
<tr class="odd">
<td colspan="4">     </td>
</tr>
<tr class="even">
<td colspan="4">     </td>
<td colspan="2" rowspan="2"> </td>
<td colspan="4" rowspan="2">     </td>
<td colspan="5" rowspan="2">     </td>
<td colspan="2" rowspan="2">     </td>
<td colspan="3" rowspan="2">     </td>
<td rowspan="2">  </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
<td rowspan="2">  </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
</tr>
<tr class="odd">
<td colspan="4">     </td>
</tr>
<tr class="even">
<td colspan="4">     </td>
<td colspan="2" rowspan="2"> </td>
<td colspan="4" rowspan="2">     </td>
<td colspan="5" rowspan="2">     </td>
<td colspan="2" rowspan="2">     </td>
<td colspan="3" rowspan="2">     </td>
<td rowspan="2">  </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
<td rowspan="2">  </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
</tr>
<tr class="odd">
<td colspan="4">     </td>
</tr>
<tr class="even">
<td colspan="4">     </td>
<td colspan="2" rowspan="2"> </td>
<td colspan="4" rowspan="2">     </td>
<td colspan="5" rowspan="2">     </td>
<td colspan="2" rowspan="2">     </td>
<td colspan="3" rowspan="2">     </td>
<td rowspan="2">  </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
<td rowspan="2">  </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
</tr>
<tr class="odd">
<td colspan="4">     </td>
</tr>
<tr class="even">
<td colspan="4">     </td>
<td colspan="2" rowspan="2"> </td>
<td colspan="4" rowspan="2">     </td>
<td colspan="5" rowspan="2">     </td>
<td colspan="2" rowspan="2">     </td>
<td colspan="3" rowspan="2">     </td>
<td rowspan="2">  </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
<td rowspan="2">  </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
</tr>
<tr class="odd">
<td colspan="4">     </td>
</tr>
<tr class="even">
<td colspan="4">     </td>
<td colspan="2" rowspan="2"> </td>
<td colspan="4" rowspan="2">     </td>
<td colspan="5" rowspan="2">     </td>
<td colspan="2" rowspan="2">     </td>
<td colspan="3" rowspan="2">     </td>
<td rowspan="2">  </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
<td rowspan="2">  </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
</tr>
<tr class="odd">
<td colspan="4">     </td>
</tr>
<tr class="even">
<td colspan="4">     </td>
<td colspan="2" rowspan="2"> </td>
<td colspan="4" rowspan="2">     </td>
<td colspan="5" rowspan="2">     </td>
<td colspan="2" rowspan="2">     </td>
<td colspan="3" rowspan="2">     </td>
<td rowspan="2">  </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
<td rowspan="2">  </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
</tr>
<tr class="odd">
<td colspan="4">     </td>
</tr>
<tr class="even">
<td colspan="4">     </td>
<td colspan="2" rowspan="2"> </td>
<td colspan="4" rowspan="2">     </td>
<td colspan="5" rowspan="2">     </td>
<td colspan="2" rowspan="2">     </td>
<td colspan="3" rowspan="2">     </td>
<td rowspan="2">  </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
<td rowspan="2">  </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
</tr>
<tr class="odd">
<td colspan="4">     </td>
</tr>
<tr class="even">
<td colspan="10"><em>If additional space is required continue on the
back.</em></td>
<td colspan="5"><strong>SUBTOTALS CARRIED FORWARD FROM THE
BACK</strong></td>
<td colspan="2">     </td>
<td colspan="3">     </td>
<td>  </td>
<td>     </td>
<td>  </td>
<td>  </td>
<td>     </td>
<td>  </td>
</tr>
<tr class="odd">
<td colspan="7"><strong>7. AMOUNT CLAIMED</strong> <em>(Total of cols.
(f), (g) and (i).)</em></td>
<td colspan="2"></td>
<td><strong>$</strong></td>
<td>     </td>
<td colspan="4"><h3 id="totals">TOTALS</h3></td>
<td colspan="2">     </td>
<td colspan="3">     </td>
<td>  </td>
<td>     </td>
<td>  </td>
<td>  </td>
<td>     </td>
<td>  </td>
</tr>
<tr class="even">
<td colspan="11" rowspan="2"><p>8. This claim is approved. Long distance
telephone calls, if shown, are certified as</p>
<p>necessary in the interest of the Government. <em>(Note: If long
distance calls are</em></p>
<p><em>included, the approving official must have been authorized, in
writing, by the head</em></p>
<p><em>of the department or agency to so certify (31 U.S.C.
680a).)</em></p></td>
<td colspan="15"><p>10. I certify that this claim is true and correct to
the best of my knowledge and</p>
<p>belief and that payment or credit has not been received by
me.</p></td>
</tr>
<tr class="odd">
<td colspan="8">PAYMENT DESIRED</td>
<td colspan="7"><h4 id="sign-original-only">Sign Original Only</h4></td>
</tr>
<tr class="even">
<td></td>
<td colspan="3"></td>
<td></td>
<td></td>
<td><h6 id="sign-original-only-1">Sign Original Only</h6></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td> </td>
<td colspan="2">CHECK</td>
<td> </td>
<td colspan="4">CASH</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="3"></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td colspan="2" rowspan="2"><p>CLAIMANT</p>
<p>SIGN HERE</p></td>
<td colspan="10" rowspan="2"></td>
<td colspan="3">DATE</td>
</tr>
<tr class="even">
<td></td>
<td colspan="3"></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td colspan="3">     </td>
</tr>
<tr class="odd">
<td colspan="4" rowspan="2"><p>APPROVING</p>
<p>OFFICIAL</p>
<p>SIGN HERE</p></td>
<td colspan="2" rowspan="2"></td>
<td colspan="4" rowspan="2">     </td>
<td>DATE</td>
<td colspan="15">11. CASH PAYMENT RECEIPT</td>
</tr>
<tr class="even">
<td>     </td>
<td colspan="11">a. PAYEE <em>(Signature</em>)</td>
<td colspan="4">b. DATE</td>
</tr>
<tr class="odd">
<td colspan="11">9. This claim is certified correct and proper for
payment.</td>
<td colspan="11" rowspan="3"></td>
<td colspan="4">     </td>
</tr>
<tr class="even">
<td></td>
<td colspan="3"></td>
<td></td>
<td></td>
<td><p id="sign-original-only-2" class="heading">Sign Original
Only</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td colspan="4">c. AMOUNT</td>
</tr>
<tr class="odd">
<td colspan="4" rowspan="2"><p>AUTHORIZED</p>
<p>CERTIFYING</p>
<p>OFFICER</p>
<p>SIGN HERE</p></td>
<td></td>
<td></td>
<td colspan="4" rowspan="2">     </td>
<td>DATE</td>
<td colspan="4"><strong>$</strong>      </td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td>     </td>
<td colspan="5"><p>12. PAYMENT MADE</p>
<p>BY CHECK NO.</p></td>
<td colspan="10">     </td>
</tr>
<tr class="odd">
<td colspan="26"><h5 id="accounting-classification">ACCOUNTING
CLASSIFICATION</h5></td>
</tr>
<tr class="even">
<td colspan="26">     </td>
</tr>
<tr class="odd">
<td colspan="26"><p><strong>STANDARD FORM 1164</strong> (REV. 11-77)</p>
<p>Prescribed by GSA, FPMR (CFR 41) 101-7</p></td>
</tr>
</tbody>
</table>

<table>
<colgroup>
<col style="width: 4%" />
<col style="width: 2%" />
<col style="width: 1%" />
<col style="width: 3%" />
<col style="width: 24%" />
<col style="width: 25%" />
<col style="width: 6%" />
<col style="width: 5%" />
<col style="width: 3%" />
<col style="width: 5%" />
<col style="width: 3%" />
<col style="width: 4%" />
<col style="width: 6%" />
<col style="width: 3%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="14"><strong>6. EXPENDITURES -
<em>Continued</em></strong></td>
</tr>
<tr class="even">
<td colspan="3" rowspan="2">DATE</td>
<td rowspan="4"><p>C</p>
<p>O</p>
<p>D</p>
<p>E</p></td>
<td colspan="2" rowspan="3"><p><em>Show appropriate code in col.
(b):</em></p>
<p><strong>A -</strong> Local travel</p>
<p><strong>B</strong> – Telephone or telegraph, or</p>
<p><strong>C</strong> – Other Expenses <em>(itemized)</em></p></td>
<td rowspan="2"><p>MILEAGE</p>
<p>RATE</p></td>
<td colspan="7"><h2 id="amount-claimed-1">AMOUNT CLAIMED</h2></td>
</tr>
<tr class="odd">
<td colspan="2" rowspan="3">MILEAGE</td>
<td colspan="2" rowspan="3"><p>FARE</p>
<p>OR TOLL</p></td>
<td rowspan="3"><p>ADD.</p>
<p>PER-</p>
<p>SONS</p></td>
<td colspan="2" rowspan="3"><p>TIPS AND</p>
<p>MISCEL-</p>
<p>LANEOUS</p></td>
</tr>
<tr class="even">
<td>20</td>
<td>  </td>
<td></td>
<td>    </td>
</tr>
<tr class="odd">
<td></td>
<td colspan="2"></td>
<td colspan="2"><em>(Explain expenditures in specific detail.)</em></td>
<td rowspan="2"><p>NO. OF</p>
<p>MILES</p>
<p><em>(e)</em></p></td>
</tr>
<tr class="even">
<td colspan="3"><em>(a)</em></td>
<td><em>(b)</em></td>
<td><em>(c)</em> FROM</td>
<td><em>(d</em>) TO</td>
<td colspan="2"><em>(f)</em></td>
<td colspan="2"><em>(g)</em></td>
<td><em>(h)</em></td>
<td colspan="2"><em>(i)</em></td>
</tr>
<tr class="odd">
<td colspan="3">     </td>
<td rowspan="2"> </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
<td rowspan="2">  </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
</tr>
<tr class="even">
<td colspan="3">     </td>
</tr>
<tr class="odd">
<td colspan="3">     </td>
<td rowspan="2"> </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
<td rowspan="2">  </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
</tr>
<tr class="even">
<td colspan="3">     </td>
</tr>
<tr class="odd">
<td colspan="3">     </td>
<td rowspan="2"> </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
<td rowspan="2">  </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
</tr>
<tr class="even">
<td colspan="3">     </td>
</tr>
<tr class="odd">
<td colspan="3">     </td>
<td rowspan="2"> </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
<td rowspan="2">  </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
</tr>
<tr class="even">
<td colspan="3">     </td>
</tr>
<tr class="odd">
<td colspan="3">     </td>
<td rowspan="2"> </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
<td rowspan="2">  </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
</tr>
<tr class="even">
<td colspan="3">     </td>
</tr>
<tr class="odd">
<td colspan="3">     </td>
<td rowspan="2"> </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
<td rowspan="2">  </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
</tr>
<tr class="even">
<td colspan="3">     </td>
</tr>
<tr class="odd">
<td colspan="3">     </td>
<td rowspan="2"> </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
<td rowspan="2">  </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
</tr>
<tr class="even">
<td colspan="3">     </td>
</tr>
<tr class="odd">
<td colspan="3">     </td>
<td rowspan="2"> </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
<td rowspan="2">  </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
</tr>
<tr class="even">
<td colspan="3">     </td>
</tr>
<tr class="odd">
<td colspan="3">     </td>
<td rowspan="2"> </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
<td rowspan="2">  </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
</tr>
<tr class="even">
<td colspan="3">     </td>
</tr>
<tr class="odd">
<td colspan="3">     </td>
<td rowspan="2"> </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
<td rowspan="2">  </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
</tr>
<tr class="even">
<td colspan="3">     </td>
</tr>
<tr class="odd">
<td colspan="3">     </td>
<td rowspan="2"> </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
<td rowspan="2">  </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
</tr>
<tr class="even">
<td colspan="3">     </td>
</tr>
<tr class="odd">
<td colspan="3">     </td>
<td rowspan="2"> </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
<td rowspan="2">  </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
</tr>
<tr class="even">
<td colspan="3">     </td>
</tr>
<tr class="odd">
<td colspan="3">     </td>
<td rowspan="2"> </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
<td rowspan="2">  </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
</tr>
<tr class="even">
<td colspan="3">     </td>
</tr>
<tr class="odd">
<td colspan="3">     </td>
<td rowspan="2"> </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
<td rowspan="2">  </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
</tr>
<tr class="even">
<td colspan="3">     </td>
</tr>
<tr class="odd">
<td colspan="3">     </td>
<td rowspan="2"> </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
<td rowspan="2">  </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
</tr>
<tr class="even">
<td colspan="3">     </td>
</tr>
<tr class="odd">
<td colspan="3">     </td>
<td rowspan="2"> </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
<td rowspan="2">  </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
</tr>
<tr class="even">
<td colspan="3">     </td>
</tr>
<tr class="odd">
<td colspan="3">     </td>
<td rowspan="2"> </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
<td rowspan="2">  </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
</tr>
<tr class="even">
<td colspan="3">     </td>
</tr>
<tr class="odd">
<td colspan="3">     </td>
<td rowspan="2"> </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
<td rowspan="2">  </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
</tr>
<tr class="even">
<td colspan="3">     </td>
</tr>
<tr class="odd">
<td colspan="3">     </td>
<td rowspan="2"> </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
<td rowspan="2">  </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
</tr>
<tr class="even">
<td colspan="3">     </td>
</tr>
<tr class="odd">
<td colspan="3">     </td>
<td rowspan="2"> </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
<td rowspan="2">  </td>
<td rowspan="2">     </td>
<td rowspan="2">  </td>
</tr>
<tr class="even">
<td colspan="3">     </td>
</tr>
<tr class="odd">
<td colspan="6"><h3
id="total-each-column-and-enter-on-the-front-subtotal-line"><em>Total
each column and enter on the front, subtotal line</em> </h3></td>
<td>     </td>
<td>     </td>
<td>  </td>
<td>     </td>
<td>  </td>
<td>  </td>
<td>     </td>
<td>  </td>
</tr>
<tr class="even">
<td colspan="14"><em>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 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 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 in
connection with the 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 6109) 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 instances; however, failure to provide the
information (other than SSN) required to support the claim may result in
delay or loss of reimbursement.</em></td>
</tr>
<tr class="odd">
<td colspan="14"><strong>STANDARD FORM 1164</strong> (REV. 11-77)
<strong>BACK</strong></td>
</tr>
</tbody>
</table>