Fillable Honors Program Reimbursement Form printable pdf download

OMB Number: 11050030

Expires 07/31/2016

U.S. Department of Justice

Honors Program Reimbursement Form

PLEASE RETURN THIS FORM WITHIN 2 WEEKS OF THE INTERVIEW

Name: ______________________________________________

Social Security Number:

___________________

Mailing Add

ress: ______________________________________

E-Mail: _________________________________

______________________________________

Telephone: ______________________________

______________________________________

FAX: ___________________________________

Traveled From: _______________ To: ________________ Round Trip? Yes

No Travel Dates: _______ to _______

From: _______________ To: ________________ Round Trip? Yes

No Travel Dates: _______ to _______

From: _______________ To: ________________ Round Trip? Yes

No Travel

Dates:

_______ to _______

Payment will be issued by electronic fund transfer. Please provide the following information on your checking or savings

account:

•

ABA Routing Number (On a checking account, this is a nine-digit number on the bottom, left side of a check. Ask

your bank if you have questions). __________________

•

Your bank account number: ________________________

Checking or

Savings

EXPENSES CLAIMED (Receipts are required for expenses over $75.00.)

Do not claim food purchases; you will receive M&IE if your travel exceeded 12 hours.

See

Honors Program Interviews & Travel

for details.

TYPE

DATE(S)

AMOUNT

Lodging (receipt required)

Lodging Tax

Taxi

(Only if pre-authorized or specifically approved due to late flight, etc)

Mileage

Total miles:

(If travel by private auto was authorized) Reimbursement is limited to the mileage

rate at the time of travel. See

for details.

Parking/Fare/Toll

(Include Metrorail, train, etc. Do not include prepaid air/rail fare.)

Miscellaneous: Itemize below. Airline baggage charges will not be reimbursed.

I certify that this claim is true and correct to the best of my knowledge and belief and that payment or credit has not been

received by me.

Signature: ____________________________________

Date: ___________________

Please fax back to the attention of your scheduler at 202-307-5851

PRIVACY ACT STATEMENT (This information is provided pursuant to the Privacy Act of 1974, 5 U.S.C.§552a(e)(3)): This form

requests personal information that is relevant and necessary for reimbursing expenses incurred during your travel for your interview(s) with

components participating in the Attorney General's Honors Program. DOJ collects this information in order to reimburse authorized

expenses. OARM has the authority to ask for this information pursuant to 5 U.S.C. §301, and 28 C.F.R. Part 0.15(b)(2). Because accepting

reimbursement for travel expenses is voluntary, you are not required to provide any personal information; however, failure to provide this

information could result in your not receiving reimbursement for your travel expenses.

DOJ USE ONLY:

APPROVED ___________________________________ DATE _________________

Honors Program Reimbursement Form

Related Articles

Related forms

Related Categories