Standard Form 1164 - Claim For Reimbursement For Expenditures On Official Business
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21. DEPARTMENT OR ESTABLISHMENT, BUREAU, DIVISION OR OFFICE
2. VOUCHER NUMBER
CLAIM FOR REIMBURSEMENT
FOR EXPENDITURES
3. SCHEDULE NUMBER
ON OFFICIAL BUSINESS
5. PAID BY
Read the Privacy Act Statement on the back of this form.
a. NAME (Last, first, middle initial)
b. SOCIAL SECURITY NO.
c. MAILING ADDRESS (Include ZIP Code)
d. OFFICE TELEPHONE NUMBER
6. EXPENDITURES (If fare claimed in col. (g) exceeds charge for one person, show in col. (h) the number of additional persons which accompanied
the claimant.)
AMOUNT CLAIMED
DATE
Show appropriate code in col. (b):
MILEAGE
C
D - Funeral Honors Detail
A - Local travel
RATE
O
B - Telephone or telegraph, or
E - Specialty Care
ADD
TIPS AND
D
C - Other expenses (itemized)
c
MILEAGE
FARE
PER-
MISCEL-
E
OR TOLL
SONS
LANEOUS
NO. OF
(Explain expenditures in specific detail.)
MILES
FROM
(a)
(b)
(c)
(d) TO
(e)
(f)
(g)
(h)
(i)
SUBTOTALS CARRIED FORWARD FROM THE
If additional space is required continue on the back.
BACK
7. AMOUNT CLAIMED (Total of cols. (f), (g) and (i).)
$
TOTALS
8. This claim is approved. Long distance telephone calls, if shown, are certified
10. I certify that this claim is true and correct to the best of my knowledge and
as necessary in the interest of the Government. (Note: If long distance calls
belief and that payment or credit has not been received by me.
are included, the approving official must have been authorized in writing, by
Sign Original Only
the head of the department or agency to so certify (31 U.S.C. 680a).)
Sign Original Only
DATE
CLAIMANT
SIGN HERE
DATE
11.
CASH PAYMENT RECEIPT
a. PAYEE (Signature)
b. DATE RECEIVED
APPROVING
OFFICIAL
SIGN HERE
9. This claim is certified correct and proper for payment.
c. AMOUNT
$
Sign Original Only
AUTHORIZED
DATE
CERTIFYING
12. PAYMENT MADE
OFFICER
BY CHECK NO.
SIGN HERE
ACCOUNTING CLASSIFICATION
STANDARD FORM 1164 (Rev. 11-77)
DoD Overprint 4/2002
Reset
Prescribed by GSA, FPMR (CFR 41) 101-7
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