OMB Number: 3064-0122 

EXPIRATION DATE: 07/31/2013 

FDIC 5210/12 (3-06) 

Federal Deposit Insurance Corporation 

FIRM TRAVEL VOUCHER 

SECTION I – TRAVELER INFORMATION 

1. NAME OF TRAVELER (Last, First, MI) 2. HOME OFFICE 3. FEDERAL TAX ID NUMBER 4. INVOICE NUMBER 

Buzz Lightyear xxx xxx xxx 

5. RESIDENCE (Include City, State, and ZIP Code) 6. FIRM NAME 7. MATTER NUMBER 

xxx Dewey Cheathem xxx 

8. DATE 

9. NATURE OF EXPENSE 

(Departure/Arrival Times are Required for Per Diem Payment) 

AMOUNTS CLAIMED 

10. Mileage 

11. Per 

 Diem 12. Lodging

13. Air 

 Fare

14. Car 

 Rental 15. Other 

10/31/2012 Purpose of Travel - Deposition of Defendant - Tampa, FL 

 leave Atlanta office@ 8:00 am 

 train from office to ATL airport $12 

 taxi from TPA airport to Deposition, arrive at 1:15 pm $24 

 taxi from Deposition to hotel $9 

 Hotel-- Best Southern $79 

 per diem, 3/4 day @ $51/day (Tampa FL) $38.25 

11/1/2012 leave hotel @ 7:30 am 

 taxi from hotel to airport $28 

 round trip airfare, ATL-TPA $319 

 train from airport to office, arrive 10:30 am $12

 per diem, 2/4 day $25.50 

 

 

16. CONTINUATION SHEET (Subtotals brought forward) 

17. TOTALS $63.75 $79 $319 $85

18. CERTIFIED CORRECT (Traveler's Signature) 19. DATE SIGNED 20. TOTAL REIMBURSEMENT

11/15/2012 $546.75

NOTE: If additional space is needed, complete and attach form FDIC 5210/12A, Firm Travel Voucher (Continuation Sheet).

SECTION II – CERTIFICATION 

I certify that I have examined this travel voucher and to the best of my knowledge and belief all costs claimed are allowable in accordance with FDIC travel 

regulations. Costs claimed here have not been previously billed to FDIC unless identified as a resubmission. 

 NAME/TITLE OF FDIC OVERSIGHT ATTORNEY SIGNATURE DATE 

Advocacio J. Brilliant/ Counsel 11/27/2012 

PRIVACY ACT STATEMENT 

The Financial Institutions Reform, Recovery and Enforcement Act of 1989, 12 U.S.C. Sec. 1441a, provides the authority to solicit the requested information, except for Social 

Security Number which is solicited under the authority of Executive Order 9397. The primary use of this information is to examine and approve reimbursement for expenses 

incurred on authorized travel by FDIC contractors. The information on this form may be disclosed to the General Accounting Office in connection with periodic audits, to Federal 

or State agencies charged with enforcing or implementing a statute, rule or regulation when it appears there may have been a violation of that statute, rule or regulation. 

Information on this form may also be disclosed as set forth in the routine uses in the FDIC's Financial Information System of records. Providing the information is voluntary; 

however, failure to provide all the requested information may result in suspension or disallowance of your travel expense claim. 

PAPERWORK REDUCTION ACT NOTICE 

Public reporting burden for this collection of information is estimated to average 1.0 hour per response, including the time for reviewing instructions, searching existing data 

sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other 

aspect of this collection of information, including suggestions for reducing this burden, to the Paper Reduction Act Clearance Officer, Legal Division, Federal Deposit Insurance 

Corporation, 550 17th Street, N.W., Washington, DC 20429, and the Office of Management and Budget, Paperwork Reduction Project (3064-0122), Washington, D.C. 20503. 

An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number