Statement Of Lost, Missing Or Unobtainable Lodging Receipt Form (Civilian Employee) printable pdf download

Statement Of Lost, Missing Or Unobtainable Lodging Receipt Form (Civilian Employee)

LOST, MISSING OR UNOBTAINABLE

STATEMENT OF

LODGING RECEIPT (Civilian Employee)

IAW FTR and the PPPM

reimbursement for the cost of lodging and lodging tax require

documentary evidence usually provided in the form of an itemized lodging receipt. When an

itemized lodging receipt or other documentary evidence is lost, destroyed, or impractical to obtain

you must provide a statement explaining the circumstances.

An itemized receipt or required documentary evidence was lost, missing or impractical to obtain

therefore it could not be submitted for reimbursement. I acquired lodging:

For the dates of:

_________________ through _________________

With the daily rate of:

$________

With daily lodging tax of:

$________

Number of Official Travelers (non-minor) sharing the same room w/ claimant ____

I am not including any special fees (e.g. pets, movies, room service, bar, laundry or sundry

charges) Some lodging fees must be claimed as separate reimbursable items; see FTR and

PPPM.

I stayed at: _________________________________________________ (Hotel / Motel)

Contact Information (phone # w/area code):___________________________________

Address: _______________________________________________________________

City: _______________________________________State:___ Zip code: ___________

Travel Under TONO: ____________________________________________________

Other remarks:

I understand that there are severe criminal and civil penalties for knowingly submitting a false,

fictitious, or fraudulent claim (U.S. Code, Title 18, Sections 287 and 1001 and Title 31, Section

3729).

Claimant Signature w/EMPLID: __________________ Date: _________________

Printed Full Name: ___________________________________________________

AO Signature w/EMPLID: _______________________Date:__________________

Printed Full Name: ___________________________________________________

*This statement must be completed by the traveler and validly signed in the same manner either

both electronically or both in ink by the Claimant and the Authorizing Official (AO).

April 2017

Statement Of Lost, Missing Or Unobtainable Lodging Receipt Form (Civilian Employee)