NMSS Procedure Approval

Agreement State Invitational Travel

Training Applications, Travel Authorizations,

and Vouchers

AD-500

Issue Date: 04/13/2015

Review Date: 04/13/2020

Laura A. Dudes /RA/

Director, NMSS/MSTR PHenderson for LDudes Date: 04/13/2015

Christian E. Einberg /RA/

Branch Chief, NMSS/MSTR/ASPB Date: 03/19/2015

Marcia J. Casby

Procedure Contact, NMSS/MSTR/ASPB /RA/ Date: 03/19/2015

ML14216A574

NOTE

Any changes to the procedure will be the responsibility of the NMSS Procedure Contact. 

Copies of NMSS procedures are available through the NRC website.
Procedure Title:

Agreement State Invitational Travel

Training Applications, Travel 

Applications, and Vouchers

Procedure Number: AD-500

Page: 1 of 4

Issue Date: 

04/13/2015

I. INTRODUCTION

This procedure describes the Division of Material Safety, State, Tribal, and Rulemaking 

Programs (MSTR), Agreement State Programs Branch (ASPB) use of Training Applications, 

Travel Applications, and Vouchers for invitational travel.

II. OBJECTIVES

A. To identify the process to request Agreement State training.

B. To identify the process to request authorization of invitational travel.

C. To identify the process to request reimbursement for authorized invitational travel.

III. BACKGROUND

ASPB provides invitational travel for State travelers to participate in NRC sponsored training, 

Integrated Materials Performance Evaluation Program (IMPEP) Reviews, Management 

Review Board (MRB) meetings, Working Groups, and Commission briefings. Other offices

may also authorize invitational travel for State travelers in accordance with their internal 

procedures.

IV. ROLES AND RESPONSIBILITIES

A. The ASPB Branch Chief, along with MSTR Division Management, is responsible for 

establishing a budget and associated funding for MSTR invitational travel.

B. The Agreement State Training and Travel Coordinator is responsible for processing 

all State invitational travel for MSTR, including Agreement State staff, State Liaison 

Officers, and Tribal staff. In the absence of the Agreement State Training and Travel 

Coordinator, urgent requests for travel authorizations should be directed to the ASPB 

Branch Chief. The Agreement State Training and Travel Coordinator processes and 

maintains a record of all State invitational travel.

C. MSTR staff is responsible for coordinating all MSTR funded State invitational travel 

with the Agreement State Training and Travel Coordinator.

D. The ASPB Branch Chief, or designee, is responsible for authorizing MSTR funded 

invitational travel and certifying that all voucher submittals are complete and 

accurate.
Agreement State Invitational Travel

Training Applications, Travel Applications, 

and Vouchers

Page: 2 of 4

Issue Date: 

04/13/2015

V. GUIDANCE

A. Guidance to NRC Staff

1. MSTR staff, with ASPB Branch Chief approval, will coordinate all MSTR funded 

State invitational travel with the Agreement State Training and Travel Coordinator

before a commitment for funding is provided to the State traveler.

2. The MSTR staff is instructed to provide the contact information for the Agreement 

State Training and Travel Coordinator and direct the State traveler to our website 

at the following link, https://scp.nrc.gov/training.html for guidance relating to 

invitational travel.

3. The Agreement State Training and Travel Coordinator accepts, reviews, and 

processes all Training Applications (see Appendix A) for Agreement State 

training.

4. The Agreement State Training and Travel Coordinator accepts all Travel 

Applications (see Appendix B) for Invitational Travel and submits the associated 

internal authorization form for approval based on the information provided on the 

Travel Application Form. The Travel Application Form must be submitted in 

order to establish authorization to travel and receive subsequent reimbursement.

5. The Agreement State Training and Travel Coordinator accepts, reviews, and 

processes all Vouchers for Reimbursement (see Appendix C), and ensures that 

they are complete and conform with Federal travel regulations, making minor 

modifications as necessary. 

B. Guidance to Agreement State Staff

1. Each Agreement State agency is responsible for designating a contact person for 

State training coordination and must notify the NRC Agreement State Training 

and Travel Coordinator of the designated individual’s name and contact 

information. This contact person may be the Radiation Control Program Director 

(RCPD) or their designee.

2. The State contact is responsible for coordinating training with the NRC 

Agreement State Training and Travel Coordinator. The State contact is 

responsible for submitting and prioritizing training applications. All prior training 

should be noted and, if submitting more than one application per course, the 

priority level must be provided. If subsequent applications are submitted, the 

priority level of all applications may require re-evaluation. If the priority levels 

change, the Agreement State Training and Travel Coordinator must be notified 

by e-mail. It is not necessary to resend applications when updating the priority 

levels.
Agreement State Invitational Travel

Training Applications, Travel Applications, 

and Vouchers

Page: 3 of 4

Issue Date: 

04/13/2015

3. Only one application should be attached to each e-mail submission. The subject 

line of the e-mail should appear as follows: 

Applicant Name/Course Number/Course Start Date

4. If the RCPD agrees that his/her hard signature is not required, the application 

may be submitted without such signature provided the RCPD is copied on the 

e-mail submission. The State contact should indicate on the Training Application 

that the RCPD acknowledges and approves the training request via e-mail. 

Applications which are submitted without a copy to the State’s RCPD will not be 

accepted without signature.

5. The State contact is responsible for notifying the NRC Agreement State Training 

and Travel Coordinator of staff terminations so that all applications for terminated 

staff are withdrawn from consideration. 

6. Upon acceptance to an activity (e.g. training class, working group meeting, etc.) 

that requires invitational travel, the traveler is required to complete the Travel 

Application Form within 10 business days from the date of acceptance (see 

Appendix B). Instructions for completing and submitting the form are provided on 

the form. If the applicant is unable to complete the Travel Application Form 

within 10 business days, the traveler must notify the Agreement State Training 

and Travel Coordinator of their intent to attend the training course. If a 

notification of intent is received by the Agreement State Training and Travel 

Coordinator, the applicant may be granted up to 10 additional business days to 

submit the Travel Application Form. If a notification of intent is not received by 

the Agreement State Training and Travel Coordinator, the applicant risks losing 

their seat at the training course and an alternate may be selected.

7. To obtain reimbursement and per diem for travel expenses, the traveler will 

complete and submit the Voucher Reimbursement Form to the Agreement State 

Training and Travel Coordinator within 15 business days following completion of 

travel. See Appendix C for instructions and a sample Voucher Reimbursement 

Form. The Voucher for Reimbursement Form must identify the course or other 

purpose of travel.

8. If the traveler has enrolled in Direct Deposit (see Appendix D), the traveler will 

receive reimbursement within approximately 4 days of submitting the Voucher 

Reimbursement Form. Otherwise, the traveler will receive a U.S. Department of 

Treasury check within approximately 2 weeks to the home address listed on the 

Voucher Reimbursement Form.
Agreement State Invitational Travel

Training Applications, Travel Applications, 

and Vouchers

Page: 4 of 4

Issue Date: 

04/13/2015

VI. APPENDICES

Appendix A – Training Application Form

Appendix B – Travel Application Form

Appendix C – Voucher Reimbursement Form and Instructions

Appendix D – Direct Deposit Form

VII. REFERENCES

NRC Management Directive 14.1, Travel.

VIII. ADAMS REFERENCE DOCUMENTS

For knowledge management purposes, all previous revisions of this procedure, as well as 

associated correspondence with stakeholders, that have been entered into ADAMS are 

listed below.

No. Date Document Title/Description Accession Number

1 11/1/2010 FSME Procedure AD-500

Invitational Travel Authorizations and Vouchers

ML103020142

2 8/28/2007 FSME Procedure AD-500 ML072420083

3 3/23/2006 Office of State and Tribal Programs (STP) Procedure 

AD-500

ML060960154

4 12/2/2002 STP Procedure AD-500 ML030330009

5 6/2/2000 STP Procedure AD-500 ML003761163
APPENDIX A

NRC SPONSORED TRAINING FOR AGREEMENT STATE STAFF

APPLICATION FOR TRAINING COURSE/WORKSHOP

Please complete and return to: AStrainingandtravel.Resource@nrc.gov. 

If you have any questions or comments about this form, please contact Marcia Casby at 301-415-6525

SECTION I

TO BE COMPLETED BY APPLICANT

Name: Click here to enter text. STATE: Click here to enter text.

E-Mail Address: Click here to enter text. U.S. Citizen: Yes ☐ No ☐

Business Phone/Ext: Click here to enter text.

Name of Organization/State: Click here to enter text.

COURSE/WORKSHOP INFORMATION

Title of Course/Workshop: Click here to enter text.

Course Number: Click here to enter text.

Start Date: Click here to enter a date. End Date: Click here to enter a date.

QUALIFICATIONS

Title: Click here to enter text.

Currently qualified as a RAM Inspector: Yes ☐ No ☐

Currently qualified as a License Reviewer: Yes ☐ No ☐ 

Primary description of student’s current track: Inspector ☐ and/or License Reviewer ☐

Please specify:

Medical ☐ Industrial ☐ X-Ray ☐ Emergency Preparedness/Response ☐

Academic ☐ Decommissioning ☐ Enforcement ☐ Other Click here to enter text.

Check Prior NRC Training:

F-104 ☐ G-108 ☐ G-109 ☐ G-205 ☐ H-111 ☐ H-115 ☐ H-117 ☐

H-119 ☐ H-120 ☐ H-121 ☐ H-122 ☐ H-123 ☐ H-201 ☐ H-304 ☐

H-305 ☐ H-308 ☐ H-312 ☐ H-313 ☐ H-314 ☐ H-315 ☐ H-410 ☐

H-411 ☐ H-413 ☐ H-500 ☐ S-201 ☐

SECTION II

TO BE COMPLETED BY THE STATE RADIATION CONTROL PROGRAM DIRECTOR

Please check the box below, if applicable:

1. State program has a critical need for training in this area ☐

Justification: Click here to enter text.

Please indicate the purpose of training:

Initial Qualification* ☐ Cross-Training: ☐ Refresher Training: ☐

Other: ☐ Click here to enter text.

* Check “Initial Qualification” only if training is required to initially qualify the student as a RAM 

Inspector/License Reviewer as part of their current duties.

Radiation Control Program Director: Click here to enter text. Date: Click here to enter a date.

Phone #: Click here to enter text.

SIGNATURE: 

If submitting more than one 

application, indicate priority level:

Priority: of: (# of Apps.)
APPENDIX B

NRC SPONSORED TRAINING FOR AGREEMENT

STATE STAFF 

TRAVEL APPLICATION FORM

TRAVEL PURPOSE

STATE:

TRAINING COURSE/WORKSHOP:

COURSE NUMBER:

LOCATION (CITY/STATE):

COURSE START DATE: COURSE END DATE:

TRAVELER 

NAME: SS#* (no dashes):

HOME ADDRESS BUSINESS ADDRESS

STREET: STREET:

CITY: CITY:

STATE: ZIP: STATE: ZIP:

WORK E-MAIL: WORK PHONE #

TRIP 

DATE OF DEPARTURE: DATE OF RETURN:

DEPARTURE CITY: RETURN CITY:

AIRLINE/FLIGHT #: AIRLINE/FLIGHT #:

DESTINATION CITY:

AIRFARE QUOTED BY EL SOL TRAVEL: $ AGENCY REFERENCE NUMBER:

R/T MILES (IF PLANNING TO DRIVE)**: STATE OWNED VEHICLE: (YES/NO):

LODGING ARRANGEMENTS

HOTEL:

HOTEL RATE:

HOTEL PHONE:

* If you have provided your social security number previously this fiscal year, we only require the last 4 digits.

** If you plan to drive a personal vehicle and claim mileage reimbursement, a cost comparative is required. If you plan to drive a State 

owned vehicle, it is not necessary to complete the Cost Comparative below

Please call El Sol Travel at 844-244-6694 and provide the travel attendant with your flight requirements. The El Sol Travel attendant 

will provide you with options, advising you of the Government Contract Carrier. Please complete this form and e-mail to

AStrainingandtravel.Resource@nrc.gov. If you have any questions, please contact the Training and Travel Coordinator, Marcia 

Casby, at 301-415-6525.

Notes:

COST COMPARATIVE TO DRIVE VERSUS FLY

(COMPELTE ONLY IF YOU PLAN TO DRIVE)

FLY DRIVE

Cost of Flight if Flying (provided by El Sol Travel) $ Total Mileage at 57.5 cents per mile: $

Airport Parking $ Additional Hotel Night (if required) $

Taxi Fare between Airport and Hotel $ Additional Per Diem (if required) $

TOTAL $ TOTAL $
APPENDIX C

TRAVEL VOUCHER

INSTRUCTIONS, CHECKLIST, & SAMPLE VOUCHER

Please note the following before completing your Voucher for reimbursement:

1. Please complete all highlighted sections (See example on the following pages). If you 

have attended NRC sponsored training courses in the past, you have already supplied 

us with your full social security number. If this is the case, you need only provide the last 

four digits of your Social Security number in box #2.

2. On page two, under “Nature of Expense” indicate the course number and title. On the

following line, indicate the per diem, as specified on your Acceptance Letter.

3. The first and last days of travel are always reimbursed at 3/4 of the M&IE. In the 

example that follows, the full per diem for M&IE is $56. Therefore, on the first and last 

days, the per diem is reimbursed at $42.

4. Rental cars will not be authorized for travel. If you indicated on the Travel Application 

Form that you would be driving your privately owned vehicle, you are authorized to 

request mileage reimbursement not to exceed the cost of airfare. You would have 

obtained a quote for airfare from El Sol Travel, Inc. to establish this amount and were 

required to complete the “Cost Comparative to Drive Versus Fly.” If you plan to drive, 

the Federal mileage reimbursement is based on the prevailing rate published by the 

U.S. General Services Administration. If you plan to drive a state owned vehicle, 

reimbursement is not applicable. 

5. The total will automatically calculate on the 2nd page and will carry forward to the 1st

page at “C - TOTAL CLAIM.”

6. Scan and return the form as soon as possible, but no later than 10 business days after 

the course, with airline itinerary and receipts to AStrainingandtravel.Resource@nrc.gov. 

If you have any questions, please contact Marcia Casby, Agreement State Training and 

Travel Coordinator, at (301) 415-6525.
CHECKLIST

NRC VOUCHER FOR REIMBURSEMENT

☐ Box 24 has been signed and dated.

☐ Box 5 is the home address where your reimbursement check will be mailed. Do not provide 

any address other than your home address. If this address has changed from what we have 

on record for you, please indicate that it is your new home address. If you have signed up for 

Direct Deposit, you have indicated “Enrolled in Direct Deposit” next to your home address.

☐ El Sol Travel fight Receipt is attached (if applicable). Please attach the ticketed flight receipt 

which you received 3 days prior to departure. Do not send the initial flight itinerary you 

received at the time of booking as this does not provide the exact amount direct billed to the 

NRC.

☐ The hotel receipt is attached. Hotel Receipt must show payment made. A Hotel “Folio” is not 

a receipt.

☐ All receipts over $50 are attached. All receipts are encouraged, but over $50 is required.

☐ Mileage has been calculated properly. Do not use the “Number of Miles” column.

☐ The course and per diem information is provided on the first two lines under “Nature of 

Expense.”

☐ Scan all items as one document and e-mail to AStrainingandtravel.resource@nrc.gov. Do not 

send unused or instruction pages of the voucher. 
NRC FORM 64 (8-2011)

EXAMINED BY

SIGNATURE -- AUTHORIZED CERTIFYING OFFICER

APPROVED BY OMB: NO. 3150-0192 EXPIRES: 08/31/2014

TRAVEL VOUCHER (PART 1) 

FOLLOW INSTRUCTIONS

NRC FORM 64 U.S. NUCLEAR REGULATORY COMMISSION 

(8-2011)

NRCMD 14.1

Exception to SF 1012

Approved by NARS 10-81

1. AUTHORIZATION NUMBER 2. SOCIAL SECURITY

 NO. (Last 4 digits)

3. NAME (Last , First, Middle Initial) 4. OFFICE TELEPHONE

6. RECLAIM VOUCHER 7. VOUCHER STATUS

YES NO PARTIAL FINAL

5. MAILING ADDRESS (Include ZIP Code)

8. TRAVEL PERIOD(S)

A. FROM (MM/DD/YYYY) B. TO (MM/DD/YYYY)

10. RESIDENCE (City and State)

13. TYPE OF TRAVEL 14. METHOD OF PAYMENT 15. AIRLINE ACCOMMODATIONS

CONUS/DOMESTIC

NONFOREIGN OUTSIDE CONUS

FOREIGN

COS

EFT PAYMENT TO 

ALTERNATE ACCOUNT

FIRST CLASS

OTHER PREMIUM CLASS

FREE UPGRADE

NON-CONTRACT

11. LEAVE TAKEN

ANNUAL

SICK

OTHER

12. COMPARATIVE 

TRAVEL

17. TRANSPORTATION METHOD OF PAYMENT

GTR/GTS ACCT/GOVT ISSUED CARD/CASH (Identify below) 18. CARRIER 19. TRANSPORTATION GTR OR TICKET

NUMBER

20. AMOUNT

16. EXPENSES CLAIMED 

(FROM NRC FORM 64A OR NRC FORM 64B)

EXPENSES AMOUNT CLAIMED 

OTHER EXPENSES

A. SUBSISTENCE AND 

OTHER EXPENSES

B. PLANE, TRAIN, BUS 

 (PAID BY TRAVELER)

C. TOTAL CLAIM

TRAVELER'S CERTIFICATION. I HEREBY ASSIGN TO THE UNITED STATES ANY RIGHT I MAY HAVE AGAINST ANY 

PARTIES IN CONNECTION WITH REIMBURSABLE TRANSPORTATION CHARGES DESCRIBED ABOVE, PURCHASED 

UNDER CASH PAYMENT PROCEDURES.

21. TRAVELER'S 

INITIALS

22. READ CAREFULLY

(If voucher includes any of the following, mark the appropriate boxes.)

REFUND DUE ON UNUSED TICKET, PARTIAL TICKET, AND/OR REFUND SLIP

(Explain in Part 2 and attach to front of voucher)

REMITTANCE ATTACHED IN THE

AMOUNT OF:

CHECK NO.

23. TRAVEL ADVANCE

ATM

FOR EXAMINER USE

AMOUNT TO BE APPLIED

BALANCE DUE

NET TO TRAVELER

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.

24.

SIGNATURE -- TRAVELER*

DATE

25. THIS VOUCHER IS APPROVED. 

SIGNATURE -- APPROVING OFFICIAL

DATE

26. EXAMINER'S ADJUSTMENTS

DATE

27. TRAVELER DESIGNATION

I DESIGNATE TO RECEIVE CASH PAYMENT OF THIS TRAVEL VOUCHER. I ACCEPT

RESPONSIBILITY FOR THE PAYMENT ONCE THE IMPREST FUND CASHIER PROPERLY DISBURSES THE CASH TO MY DESIGNEE.

SIGNATURE -- TRAVELER DATE

28. CASH PAYMENT OF TRAVEL VOUCHER (For Cashier Use)

RECEIVED CASH IN

THE AMOUNT OF: $

FOR

SIGNATURE DATE NRC BADGE NUMBER

29. THIS VOUCHER IS CERTIFIED CORRECT AND

 PROPER FOR PAYMENT

DATE

30. ACCOUNTING CLASSIFICATION (For Division of Financial Services Use)

A.

COST

B.

PURPOSE

CODE

C.

BFY

D. COST

ORGANIZATION

CODE

E.

JOB

CODE

F. (2110-S)

SUBSISTENCE

AND OTHER

G. (2120-D)

COMMON

CARRIER

H.

TOTAL

DOMESTIC

FOREIGN

Fraudulent Claim -- Falsification of an item in an expense account works a forf eiture of the Claim (28 U.S.C. 2514) and may result in a fine of not more than $10,000 or imprisonment of not more than

5 years or both (18 U.S.C. 287; id. 1001) *

TRAVELER'S COPY ADVANCE COPY MEMORANDUM AUTHORIZATION AUDIT FUNDS CONTROL

9. OFFICIAL DUTY STATION (City and State)(drop down list or fill in)

OTHER

TOTAL ADVANCE RECEIVED (Traveler Must Complete)

HEADQUARTERS TO BE PAID BY EFT

OTHER

$

Printed Name of Traveler:

Printed Name of Approving Official:

2a. NON-NRC SSN

 (9 digits)

Estimated burden per response to comply with this voluntary collection request: 1 

hour for NRC Forms 64 and 64A or 64B. NRC uses the information to authorize 

payment for official travel. Forward comments regarding burden estimate to the 

Information Services Branch (T-5 F53), U.S. Nuclear Regulatory Commission, 

Washington, DC 20555-0001, or by e-mail to Infocollects.Resource@nrc.gov, and 

to the Desk Officer, Office of Information and Regulatory Affairs, NEOB-10202, 

(3150-0192), Office of Management and Budget, Washington, DC 20503. If a 

means used to impose an information collection does not display a currently valid 

OMB control number, the NRC may not conduct or sponsor, and a person is not 

required to respond to, the information collection. 

2a. NON-NRC SSN

3. NAME (Last , First, Middle Initial) 4. OFFICE TELEPHONE

5. MAILING ADDRESS (Include ZIP Code)

10. RESIDENCE (City and State)

7. VOUCHER STATUS

FINAL

6. RECLAIM VOUCHER

NO

A. FROM (MM/DD/YYYY) B. TO (MM/DD/YYYY)

C. TOTAL CLAIM

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.

SIGNATURE -- TRAVELER*

Printed Name of Traveler:

Home Address

Home Address (City/State)

08/10/2014 08/15/2014

 $0.00 

 $997.90 

✔ ✔
TRAVEL VOUCHER (PART 2)

SCHEDULE OF EXPENSES AND AMOUNT CLAIMED

FOLLOW INSTRUCTIONS

NRC FORM 64A U.S. NUCLEAR REGULATORY COMMISSION 

(8-2011) 

NRCMD 14.1 

Exception to SF 1012 

Approved by NARS 10-81

PAGE OF

NAME (Last, First, MI) AUTHORIZATION NO. DEPART FROM OFFICE

DATE (MM/DD/YYYY) TIME (ie. 1:00)

A.M.

P.M.

DATE

20 NATURE OF EXPENSE

AUTHORIZED 

MILEAGE (ie.50)

¢

NUMBER

OF

MILES

AMOUNT

CLAIMED

NRC FORM 64A (8-2011)

TRAVELER'S COPY ADVANCE COPY MEMORANDUM AUTHORIZATION AUDIT FUNDS CONTROL

GRAND TOTAL - THIS PAGE 

(Amount to be included in Item 16.C, Part 1) 

NAME (Last, First, MI)

DATE (MM/DD/YYYY)

DATE

20

GRAND TOTAL - THIS PAGE 

nt to be incl ded in Item 16 C Part 1)

TIME (ie. 1:00)

2:00

14

S-201 Materials Control & Security Systems & Principles (95/56/151)

Per Diem ($94 hotel / $56 Meals & Incidentals)

08/10/2014 Personal Vehicle from home to airport (12 miles x 57.5 cents/mile)

08/10/2014 Taxi from airport to hotel

08/15/2014 Taxi from training site to airport

08/10/2014 Hotel ($94 x 5 nights = $470.00) 08/14/2014

Hotel Taxes/Fees ($16.22 x 5 nights = $81.10)

08/10/2014 First Day Partial Per Diem (3/4 of $56 = $42.00)

08/11/2014 Full Per Diem ($56 x 4 days = $224.00) 08/14/2014

08/15/2014 Last Day Partial Per Diem (3/4 of $56 = $42.00)

08/10/2014 Airline Excess Baggage Fee ($25 each way) 08/15/2014

08/15/2014 Personal Vehicle from airport to home (12 miles x 57.5 cents/mile)

08/10/2014 Airport Parking 08/15/2014

0.00

0.00

0.00

6.90

0.00

15.00

0.00

18.00

 $997.90 

0.00

470.00

0.00

81.10

0.00

42.00

0.00

224.00

0.00

42.00

0.00

50.00

0.00

6.90

0.00

42.00

✔ 08/10/2014
APPENDIX D

DIRECT DEPOSIT AUTHORIZATION FORM

FOR AGREEMENT STATE TRAINING/TRAVEL REIMBURSEMENTS

ACCOUNT HOLDER INFORMATION

Last Name: First Name: Initial:

Social Security Number:

Work Phone:

Action: New ☐ Change ☐ Cancel ☐ Effective Date:

ACCOUNT INFORMATION

Name of Financial Institution:

Routing Number:

Account Number:

Type of Account: Checking ☐ / Savings ☐

I hereby authorize the U.S. Nuclear Regulatory Commission (NRC) to initiate electronic deposits 

to my account at the financial institution named above. I agree not to hold the NRC responsible 

for any delay or loss of funds due to incorrect or incomplete information supplied by me or by my 

financial institution or due to an error on the part of my financial institution in depositing funds to 

my account.

This agreement will remain in effect until the NRC receives a written notice of cancellation from 

me or my financial institution, or until I submit a new direct deposit form.

SIGNATURE

Authorized Signature (Primary): Date:

Authorized Signature (Joint): Date

Find Routing Number on Your Check

Return to: Mary.Matheson@nrc.gov

Direct Questions to Mary Matheson, 301-415-8748