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1ONS TO TRAVELER (Unlisted item§ are self-explanatory) Complete this pace . . . : : information ’ Col. (c) \f the voucher includes Com- Col, (d) | Show amount incurred for each meal, including tax and tips, and daily total | if this isa .. per diem allowances for plete thru (9) § meal cost. continuation OF es members of employee's only, (h) Show expenses, such as: laundry, cleaning and pressing of clothes, tips to bellboys, sheet. PAGES 2 ii jate family ,sh for porters, etc, (other than for meals). ae her. ° name ‘ ow aewual (i) Comptete for per diem and actual expense travel. TRAVEL AUTHORIZATION NO. ow . : Nes, ages, H j) Show total subsistence expense incurred for actual expense travel. < and [elationship to em- expense (m) Show per diem amount, limited to maximum rate, Or if travel on actual expense, show AMOUNTS ployee and marital status travel the lesser of the amount from col. {j) or maximum rate. CLAIMED of children (unless:infor- (n) Show expenses, such as: taxi/limousine fares, air fare {if purchased with cash), local or [TRAVELER'S LAST NAME — “ matin i ae long distance telephone calls for Government business, car rental, relocation other than . b?E s shown on the \ 4 . : Df A . subsistence, etc. ry travdl authorization.) ° : . 2 OATF DESCRIPTION : ITEMIZED SUBSISTENCE EXPENSES MILEAGE AMOUNT CLAIMED ‘ computation] or other explanations amipm) | of expense) fa) (b) . wages | _conrmaernas. 43 m Wn c @ = wo 4 m 4 ie) m NO.OF | MILEAG MILES OTHER BREAK FAST |LUNCH (d) . fe) LODGING {SUBSISTENCE DINNER ’ EXPENSE ff, TOTAL (9) i) {m) ~ ~~ =m = => = > > - ! SUBTOTALS it additional space is required, continue on another SF 1012-A BACK. leaving the front blank. . TOTALS. in compliance with the Privacy Act df 1974, the following information is pro- criminal, of regulatory investigations or prosecutions, or when pursuant to a vided: Solicitation of the information on this ferm is authorized by 5 U.S.C. requirement by this agency in connection with the hiring or firing of an} &ater grand total of columns (I), (m) and Chap. 57 as implemented by the Feeral Travel Flegulations (FPMR 101 7), employee, the issuance of a security clearance, or investigations of the per-| (a), below and in item 13 on the front of E.0, 11609 of July 22, 1971, E.0. 11012 of March 27, 1962, E.0, 9397 of formance of official duty while in Government service. Your Social Security} this form. November 22, 1943, and 26 U.S.C. G011(b) and 6109. The primaryipurpose Account Number (SSN) is solicited under the authority of the Internal Sie requested jintorme on is to determine payment or reimbursement to Revenue Code (26 U.S.C, 6011(b) and 6109) and E.O. 9397, November 22, a la @ travel and/or relocation expenses jncurred 1943, for use as a tax payer and/or employee identification number; disclosure e administrative authorization and to record and maintain costs of, such feimbursements to the Government. The information will be used! by‘ officers and employees whg have a need for the information in the performance of their official duties.| The information may be disclosed to appropriate Federal, State, local, or |foreig is MANDATORY on vouchers claiming travel and/or relocation allowance expense reimbursement which is, or may be, taxable income. Disclosure of your SSN and other requested information is voluntary in all other instances; amount = [ however, failure to provide the information (other than SSN) required to AMOUNT agencies, when relevant.to civil, support the claim may result in delay or loss of reimbursement. CLAIMED % U.S. GOVERICENT PRINTING OrFic: | 1981 0 ~ 341-$26 (6509) . STANDARD FORM 1012 BACK (10-77)