FDIC 5210/12 (5-21) Page of 

OMB Number: 3064-0122 

Expiration Date: 01/31/2023

Federal Deposit Insurance Corporation 

FIRM TRAVEL VOUCHER

 PRIVACY ACT STATEMENT 

The FDIC is authorized to request this information from you by 12 U.S.C § 1819, and Executive Order 9397 as amended. The 

information collected will be primarily used to process your request for travel expense reimbursement. Furnishing the requested 

information is voluntary, but failure to provide the requested information in whole or in part may delay or prohibit any further 

consideration of your request for travel expense reimbursement. The information you provide may be provided to appropriate Federal, 

state, local or foreign agencies and law enforcement authorities; to a court, administrative tribunal, or a party in litigation; and to 

contractors, agents and other third parties as authorized by law and in accordance with any of the other routine uses described in the 

FDIC Financial Information Management Records (FDIC 30-64-0012) System of Records available at www.fdic.gov/about/privacy/. If 

you have questions or concerns about the collection or use of the information, you may contact the FDIC's Chief Privacy Officer at 

Privacy@fdic.gov.

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. 

Page down to access form 5210/12
FDIC 5210/12 (5-21) Page of 

OMB Number: 3064-0122 

Expiration Date: 01/31/2023

Federal Deposit Insurance Corporation 

FIRM TRAVEL VOUCHER

INSTRUCTIONS: Please provide all information requested.

SECTION I - TRAVELER'S INFORMATION

1. Name 2. Telephone 3. Federal Tax ID 4. Invoice Number

5. Address (Street, City, State, ZIP Code)

6. Firm Name 7. Matter Number

SECTION II - EXPENSES

8. Complete the following.

Amounts Claimed

Date

Nature of Expense 

(Departure/Arrival Times are Per Diem Payment) Mileage Per Diem Lodging Air Fare Car Rental Other

 Subtotals:

Total Reimbursement: 

SECTION III - TRAVELER'S CERTIFICATION

I certify the amounts claimed in Section II - Expenses is correct.

9. Signature 10. Date

SECTION IV - FDIC OVERSIGHT ATTORNEY 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.

11. Name 12. Title

13. Signature 14. Date