Travel Voucher - Standard Form 1012
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1
2TRAVEL VOUCHER
1. DEPARTMENT OR ESTABLISHMENT,
2.
TYPE OF TRAVEL
3.
VOUCHER NO.
BUREAU DIVISION OR OFFICE
TEMPORARY DUTY
(Read the Privacy Act
4.
SCHEDULE NO.
PERMANENT CHANGE
Statement on the back)
OF STATION
5.
a.
NAME (Last, first middle initial)
b.
SOCIAL SECURITY NO.
6.
PERIOD OF TRAVEL
a.
FROM
b.
TO
T
R
A
V
c.
MAILING ADDRESS (Include ZIP Code)
d.
OFFICE TELEPHONE NO.
7.
TRAVEL AUTHORIZATION
E
L
a.
NUMBER(S)
b.
DATE(S)
E
P
e.
PRESENT DUTY STATION
f.
RESIDENCE (City and State)
A
Y
E
E
10.
CHECK NO.
8.
TRAVEL ADVANCE
9.
CASH PAYMENT RECEIPT
11.
PAID BY
a.
Outstanding
a.
DATE RECEIVED
b.
AMOUNT RECEIVED
b.
Amount to be applied
$
c.
Amount due Government
c.
PAYEE'S SIGNATURE
(Attached)
Check
Cash
d.
Balance outstanding
12.
GOVERNMENT
I hereby assign to the United States any right I may have against any parties in connection with reimbursable
Traveler's Initials
TRANSPORTATION
transportation charges described below, purchased under cash payment procedures (FPMR 101-7)
REQUESTS, OR
TRANSPORTATION
MODE,
POINTS OF TRAVEL
ISSUING
TICKETS, IF PUR-
AGENT'S
CLASS OF
DATE
CAR-
CHASED WITH CASH
VALUATION
SERVICE
ISSUED
FROM
TO
RIER
(List by number below
OF TICKET
AND ACCOM-
(Initials)
and attach passenger
MODATIONS
coupon, if cash is used
show claim on reverse
(a)
((b)
(c)
(d)
(e)
(f)
side.)
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 on the average cost of lodging incurred during the period covered
by this voucher.
AMOUNT
TRAVELER
DATE
CLAIMED
$
SIGN HERE
NOTE:
Falsification of an item in an expense account works a forfeiture of claim (28 U.S.C. 2514) and may result in a fine of
not more than $30,000 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
17.
FOR FINANCE OFFICE USE ONLY
necessary in the interest of the Government, (NOTE: If long distance telephone calls
COMPUTATION
are included, the approving official must have been authorized in writing by the
a.
DIFFER-
head of the department or agency to so certify (31 U.S.C. 680a).
$
ENCES
IF ANY
DATE
(Explain
APPROVING
and show
OFFICIAL
amount)
SIGN HERE
b.
TOTAL VERIFIED CORRECT FOR
15.
LAST PRECEDING VOUCHER PAID UNDER SAME TRAVEL AUTHORIZATION
CHARGE TO APPROPRIATION
a.
VOUCHER NO.
b.
D.O. SYMBOL
c.
MONTH &
YEAR
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.
ACCOUNTING CLASSIFICATION
1012-114
STANDARD FORM 1012 (REV. 10-77)
Prescribed by GSA FPMR (41 CFR) 101-7
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