Sponsor Post-Travel Disclosure Form - U.s. House Of Representatives Committee On Ethics

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U.S. House of Representatives
Committee on Ethics
This form must be completed by an officer of any organization that served as the primary trip sponsor in providing travel expenses or
reimbursement for travel expenses to House Members, officers, or employees under House Rule 25, clause 5. A completed copy of
the form must be provided to each House Member, officer, or employee who participated on the trip within 10 days of their return.
You must answer all questions, and check all boxes, on this form for your submission to comply with House rules and the
Committee’s travel regulations. Failure to comply with this requirement may result in the denial of future requests to sponsor trips
and/or subject the current traveler to disciplinary action or a requirement to repay the trip expenses.
NOTE: Willful or knowing misrepresentations on this form may be
subject to criminal prosecution pursuant to 18 U.S.C. § 1001.
1. Sponsor(s) (who paid for the trip): __________________________________________________________________
2. Travel Destination(s): ____________________________________________________________________________
3. Date of Departure: _____________________________ Date of Return: __________________________________
4. Name(s) of Traveler(s): __________________________________________________________________________
(NOTE: You may list more than one traveler on a form only if all information is identical for each person listed.)
5. Actual amount of expenses paid on behalf of, or reimbursed to, each individual named in response to Question 4:
Total Lodging
Total Meal
Other Expenses
(dollar amount per item and description)
6. All expenses connected to the trip were for actual costs incurred and not a per diem or lump sum payment. (Signify
statement is true by checking box):
I certify that the information contained in this form is true, complete, and correct to the best of my knowledge.
Signature: _____________________________________________________________________________________
Name: ______________________________________________ Title: ____________________________________
Organization: __________________________________________________________________________________
I am an officer of the above-named organization (signify statement is true by checking box):
Address: ______________________________________________________________________________________
Telephone number: ______________________________________________________________________________
Email Address: ________________________________________________________________________________
Committee staff may contact the above-named individual if additional information is required.
If you have questions regarding your completion of this form, please contact the Committee on Ethics at (202) 225-7103.
Version date 2/2013 by Committee on Ethics


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