Standard Form 1164 - Claim For Reimbursement For Expenditures On Official Business Page 2

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6. EXPENDITURES - Continued

DATE

AMOUNT CLAIMED

Show appropriate code in col. (b):

MILEAGE

A - Local travel

D - Funeral Honors Detail

RATE

B - Telephone or telegraph, or

E - Specialty Care

ADD

TIPS AND

C - Other expenses (itemized)

MILEAGE

FARE

PER-

MISCEL-

OR TOLL

SONS

LANEOUS

NO. OF

(Explain expenditures in specific detail.)

MILES

FROM

(a)

(b)

(c)

(d) TO

(e)

(f)

(g)

(h)

(i)

Total each column and enter on the front, subtotal line.

In compliance with the Privacy Act of 1974, the following information is provided: Solicitation of the information on this form is authorized by 5 U.S.C. Chapter 57 as

implemented by the Federal Travel Regulations (FPMR 101-7), E.O. 11609 of July 22 1971, E.O. 11012 of March 27, 1962, E.O. 9397 of November 22, 1943, and

26 U.S.C. 6011(b) and 6109. The primary purpose of the requested information is to determine payment or reimbursement to eligible individuals for allowable travel

and/or other expenses incurred under appropriate administrative authorization and to record and maintain costs of such reimbursements to the Goverment. The

information will be used by Federal agency officers and employees who have a need for the information in the performance of their official duties. The information may

be disclosed to appropriate Federal, State, local, or foreign agencies, when relevant to civil, criminal, or regulatory investigations or prosecutions, or when pursuant to

a requirement by this agency in connection with the hiring or firing of an employee, the issuance of a security clearance, or investigations of the performance of official

duty while in Government service. Your Social Security Account Number (SSN) is solicited under the authority of the Internal Revenue Code (26 U.S.C. 6011(b) and

6109) and E.O. 9397, November 22, 1943, for use as a taxpayer and/or employee identification number; disclosure is MANDATORY on vouchers claiming payment or

reimbursement which is, or may be, taxable income. Disclosure of your SSN and other requested information is voluntary in all other instances; however, failure to

provide the information (other than SSN) required to support the claim may result in delay or loss of reimbursement.

DoD Overprint 4/2002

STANDARD FORM 1164 Back (Rev. 11-77)

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