Statement Of Lost, Missing Or Unobtainable Lodging Receipt Form (Civilian Employee) (Page 2 of 2) in pdf

Statement Of Lost, Missing Or Unobtainable Lodging Receipt Form (Civilian Employee) Page 2

LOST, MISSING OR UNOBTAINABLE

STATEMENT OF

LODGING RECEIPT (Uniformed Member)

IAW JTR and the PPPM

reimbursement for the cost of lodging and lodging tax require an

itemized lodging receipt. When an itemized lodging receipt is lost, destroyed, or impractical to

obtain you must furnish a statement explaining the circumstances.

An itemized receipt 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 JTR 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) Page 2