Fillable Travel Voucher printable pdf download

TRAVEL VOUCHER

3. VOUCHER NO.

1. DEPARTMENT OR ESTABLISHMENT,

2. TYPE OF TRAVEL

(Read the Privacy Act

BUREAU, DIVISION, OR OFFICE

TEMPORARY DUTY

Statement on the

4. SCHEDULE NO.

back)

PERMANENT CHANGE

OF STATION

b. SOCIAL SECURITY NUMBER

6. PERIOD OF TRAVEL

a. NAME (Last, first, middle initial)

a. FROM

b. TO

c. MAILING ADDRESS (Include ZIP Code)

d. OFFICE TELEPHONE NO.

7. TRAVEL AUTHORIZATION

a. NUMBER(S)

b. DATE(S)

e. PRESENT DUTY STATION

f. RESIDENCE (city and State)

10. CHECK NO.

8. TRAVEL ADVANCE

9. CASH PAYMENT RECEIPT

11. PAID BY

a. DATE RECEIVED

b. AMOUNT RECEIVED

a. Outstanding

b. Amount to be applied

c. PAYEE'S SIGNATURE

c. Amount due Government

(Attached:

Check

Cash)

d. Balance outstanding

12. GOVERNMENT

Traveler's Initials

I hereby assign to the United States any right I may have against any parties in connection with reimbursable

TRANSPORTATION

transportation charges described below, purchased under cash payment procedures (FPMR 101-7).

REQUEST, OR

TRANSPORTATION

TICKETS, IF PUR-

MODE,

ISSUING

AGENT'S

POINTS OF TRAVEL

DATE

CHASED WITH CASH

CLASS OF

CARRIER

VALUATION

(List by number below

ISSUED

SERVICE

and attached passenger

(Initials)

OF TICKET

AND ACCOM-

coupon; if cash is used

FROM

MODATIONS

show claim on reverse

(e)

(b)

(f)

(a)

(d)

side.)

(c)

13. I certify that this voucher is true and correct to the best of my knowledge and belief, and that payment or credit has not

been received by me. When applicable, per diem claimed is based and the average cost of lodging incurred during the period

covered by this voucher.

DATE

AMOUNT

TRAVELER

CLAIMED

SIGN HERE

NOTE; Falsification of an item in an expense account works a forfeiture of claim (27 U.S.C. 2514) and may result in a fine

of not more than $10,000 or imprisonment for not more than 5 years or both (18 U.S.C. 287; i.d. 1001).

14. This voucher is approved. Long distance telephone calls, if any, are certified as necessary

17. FOR FINANCE OFFICE USE ONLY

in the interest of the Government. (NOTE: If long distance telephone calls are included,

COMPUTATION

the approving official must have been authorized in writing by the head of the

a. DIFFER-

department or agency to so certify. (31 U.S.C. 680a).

ENCES,

IF ANY

APPROVING

DATE

(Explain

OFFICIAL

and show

SIGN HERE

amount)

15. LAST PRECEDING VOUCHER PAID UNDER SAME TRAVEL AUTHORIZATION

a. VOUCHER NO.

b. D.O. SYMBOL

c. MONTH &

b. TOTAL VERIFIED CORRECT FOR

YEAR

CHARGE TO APPROPRIATION

Certifier's Initials:

16. THIS VOUCHER IS CERTIFIED CORRECT AND PROPER FOR PAYMENT

c. APPLIED TO TRAVEL ADVANCE

(Appropriation symbol):

AUTHORIZED

CERTIFYING

DATE

OFFICIAL

d. NET TO TRAVELER

SIGN HERE

18. ACCOUNT CLASIFICATION

STANDARD FORM 1012

NSN 7540-00-634-4180

(REV. 10-77)

Prescribed by GSA, FPMR (41 CFR) 101-7

Travel Voucher

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