◆ SpookStack

— INSTRUCTIONS TO TRAVELER (Unlisted items are self-explanatory) Complete this pace ‘ . information 1 SCHEDULE Col, (c) 11) the voucher includes Com. [ Col. (d) } Show amount incurred for each meal, including tax and tips, and daily total if this isa OF per diem allowances for plete thru (9) J meal cost. continuation OF . SES embers of employee's ohly fh) Show expenses, such as: laundry, cleaning and pressing of clothes, tips to bellboys, sheet. PAGES EXPENSE Lmediate family. sh fo. Porters, etc. (other than for meals), . onedine —- now etna fi) Complete for per diem and actual expense travel. TRAVEL AUTHORIZATION NO. AND embers names, ages, ‘ {j) Show total subsistence expense incurred for actual expense travel. ‘ and relationship to em- expense (m) Show per diem amount, limited to maximum rate, or if travel on actual expense, show AMOUNTS oyee 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), localor JTRAVELER'S LAST NAME J ‘on is shown on the ! long distance telephone calls for Government business, car rental, relocation other than subsistence, etc, . 1 authorization.) - DATE DESCRIPTION ITEMIZED SUBSISTENCE EXPENSES AMOUNT CLAIMED NO.OF | MILEAGE |SUBSISTENCE! MILES (i) tk) PE ; Z|. (|e) (a) f _ soddit SUBTOTALS b ih additional space is required, Gontinue on another SF 1012-A BACK. leaving the front blank. TOTALS B - In compliance with the Privacy Ack of 1974, the following inform in is pro- criminal, or regulatory investigations or prosecutions, or when pursuant to a vided: Solici 9 of the :informatjon on this form 1s authorized ty 5 U.S.C. requirement by this agency in connection with the hiring or firing of an} E?ter grand total of columns (i), &) and Chap. 57 as implemented by the Federal Travel Regulations (FPMR 101-7), employee, the issuance of a security clearance, or investigations of the per- (o), below and in item 13 on the front a: E.0, 11609 of July 22, 1971, E.d. 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.Q. 6011lb) and 6109. The Primary Purpose Account Number (SSN) is solicited under the authority of the Internal of the requested information is tg determine Payment or reimbursement to Revenue Code (26 U.S.C. 6011(b) and 6109) and E.0. 9397, November 22, eligible individuats for allowable }ravel and/or relocation expensés incurred 1943, for use as a tax payer and/or employee identification number; disclosure under appropriate administrative puthorization and to record and maintain 1s MANDATORY on vouchers claiming travel and/or relocation allowance costs of such reimbursements to the Government. \ The information will be expense reimbursement which is, or may be, taxable income. Disclosure off TOTAL | 5 used by‘officers and employees who have a need for the information in the your SSN and other requested information is voluntary in all other instances:] AMOUNT performance of their of ¢ e The information may be disclosed to however, failure to provide the information (other than SSN) required to LAIMED > appropriate Federal, State, local, or foreign agencies, when relevant to civil, support the claim may result in delay or loss of reimbursement, CLAI 2: 1981 O = 3H1-$26 (oS09) STANDARD FORM 1012 BACK (10-77) © U.S. OVERNMENT PRIEING OTL