Member/officer Post-Travel Disclosure Form - U.s. House Of Representatives Committee On Ethics
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1 Original Amendment
U.S. House of Representatives
Committee on Ethics
MEMBER / OFFICER POST-TRAVEL DISCLOSURE FORM
This form is for disclosing the receipt of travel expenses from a private source for travel taken in connection with a
Member or officer’s official duties. This form does not eliminate the need to report privately-funded travel on the
Member or officer’s annual Financial Disclosure Statement. In accordance with House Rule 25, clause 5, you must
complete this form and file it with the Clerk of the House, 135 Cannon House Office Building, within 15
days after travel is completed. Please do not file this form with the Committee on Ethics.
NOTE: Willful or knowing misrepresentations on this form may be
subject to criminal prosecution pursuant to 18 U.S.C. § 1001.
1. Name of Traveler: ________________________________________________________________
or
2. a. Name of accompanying relative: ________________________________________
None
b. Relationship to Traveler:
Spouse
Child
Other (specify): ______________________
3. a. Dates of departure and return: Departure: _________________ Return: __________________
or
b. Dates at personal expense: ______________________________________________
None
4. Departure city: ______________ Destination: __________________
Return city: __________
5. Sponsor(s) (who paid for the trip): ____________________________________________________
6. Describe meetings and events attended (attach additional pages if necessary): __________________
________________________________________________________________________________
7. Attached to this form are EACH of the following (signify that each item is attached by checking the
corresponding box):
a.
a completed Sponsor Post-Travel Disclosure Form;
b.
the Primary Trip Sponsor Form completed by the trip sponsor prior to the trip, including all
attachments and Grantmaking or Non-Grantmaking Sponsor Forms;
c.
page 2 of the completed Traveler Form submitted by the Member or officer; and
d.
the letter from the Committee on Ethics approving my participation on this trip.
8. a. I represent that I participated in each of the activities reflected in the sponsor’s agenda. (Signify
that statement is true by checking box):
b. If not, explain: ________________________________________________________________
_____________________________________________________________________________
I certify that the information contained in this form is true, complete, and correct to the best of my
knowledge. I have determined that all of the expenses on the attached Sponsor Post-Travel Disclosure
Form were necessary and that the travel was in connection with my duties as a Member or officer of the
U.S. House of Representatives and would not create the appearance that I am using public office for
private gain.
SIGNATURE OF MEMBER: __________________________________________________________
DATE: ________________________
Version date 2/2015 by Committee on Ethics
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