CUI when filled in

ACCOUNTING CLASSIFICATION

A - Local Travel D. Funeral Honors Detail

B - Telephone or Telegraph

C - Other expenses (itemized)

E. Specialty Care

NUMBER OF 

MILES 

(e)

OPTIONAL FORM 1164 (REV. 11/2017)

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).)

If additional space is required continue on the back. SUBTOTALS CARRIED FORWARD FROM THE 

BACK

TOTALS

10. 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. 

DATE

CLAIMANT 

SIGN HERE

11. CASH PAYMENT RECEIPT

a. PAYEE (Signature) b. DATE RECEIVED

c. AMOUNT

12. PAYMENT MADE 

 BY CHECK NUMBER

Sign Original Only

DATE

Sign Original Only

Sign Original Only

DATE

9. This claim is certified correct and proper for payment.

7. AMOUNT CLAIMED (Total of columns (f), (g) and (i).) $

FARE 

 OR 

TOLL 

(g)

MILEAGE 

(f)

TIPS AND 

MISCELLANEOUS 

(i)

ADD 

PERSONS

(h)

Read the Privacy Act Statement on the back of this form. 5. PAID BY

Show appropriate code in column (b): MILEAGE RATE

(Enter Whole 

Numbers Only)

6. EXPENDITURES (If fare or toll claimed in column (g) exceeds charge for one person, show in column (h) the number of additional persons which 

accompanied the claimant.)

4. 

C 

L 

A 

I 

M 

A 

N 

T

d. OFFICE TELEPHONE NUMBER

a. NAME (Last, first, middle initial) b. EMPLOYEE ID NUMBER

c. MAILING ADDRESS (Include ZIP Code)

3. SCHEDULE NUMBER

1. DEPARTMENT OR ESTABLISHMENT, BUREAU, DIVISION OR OFFICE 2. VOUCHER NUMBER

CLAIM FOR REIMBURSEMENT 

FOR EXPENDITURES 

ON OFFICIAL BUSINESS

AMOUNT CLAIMED

(Explain expenditures in specific detail.)

(a) (c) FROM (d) TO

DATE C 

O 

D 

E 

(b)

APPROVING 

OFFICIAL 

SIGN HERE

AUTHORIZED 

CERTIFYING 

OFFICER 

SIGN HERE

$

c
CUI when filled in

6. EXPENDITURES -- Continued

DATE AMOUNT CLAIMED

(a) (c) FROM

C 

O 

D 

E 

(b)

D. Funeral Honors Detail

E. Specialty Care

A - Local Travel

B - Telephone or Telegraph

C - Other expenses (itemized)

Show appropriate code in column (b):

(Explain expenditures in specific detail.)

MILEAGE 

RATE

NUMBER OF 

MILES 

(d) TO (e)

MILEAGE 

(f)

FARE 

 OR 

TOLL 

(g)

ADD 

PERSONS

(h)

TIPS AND 

MISCELLANEOUS 

(i)

Total each column and enter on the front, subtotal line.

In compliance with the Privacy Act of 1974, the following information is provided: Solicitation of the information on this form is authorized by Executive Order 11609 of July 22, 1971, Executive Order 11012 of March 

27, 1962, Executive Order 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 of reimbursements from 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. An Employee Identification (ID) Number is solicited under the authority of the Internal Revenue 

Code (26 U.S.C. 6011(b) and 6109) and Executive Order 9397, November 22, 1943, for use as a taxpayer and/or identification number. Disclosure is MANDATORY on vouchers claiming payment or reimbursement 

which is, or may be, taxable income. Disclosure of your ID Number and other requested information is voluntary in all other instances. Failure to provide the information (other than ID Number) required to support 

the claim may result in delay or loss of reimbursement. 

OPTIONAL FORM 1164 (REV. 11/2017) BACK

c