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OCR Page 1 of 1191. DEPARTMENT OR ESTABLISHMENT, BUREAU, DIVISION OR OFFICE
2. VOUCHER NUMBER
CLAIM FOR REIMBURSEMENT
FOR EXPENDITURES
3. SCHEDULE NUMBER
ON OFFICIAL BUSINESS
Read the Privacy Act Statement on the back of this form.
5. PAID BY
a. NAME (Last, first, middle intial)
b. SOCIAL SECURITY NO.
CLAIMANT 4.
c. MAILING ADDRESS (Include ZIP Code)
d. OFFICE TELEPHONE NUMBER
6. EXPENDITURES (If fare claimed in col. (g) exceeds charge for one person, show in col. (h) the number of additional persons which accompanied the
claimant.)
DATE
Show appropriate code in col. (b):
AMOUNT CLAIMED
mooo
A-Local travel
MILEAGE
RATE
D
B-Telephone or telegraph, or
19
E
C-Other Expenses (itemized)
¢
MILEAGE
FARE
ADD.
TIPS AND
OR TOLL
PER-
MISCEL-
(Explain expenditures in specific detail.)
NO. OF
SONS
LANEOUS
MILES
(a)
(b)
(c) FROM
(d) TO
(e)
(f)
(g)
(h)
(i)
If additional space is required continue on the back.
SUBTOTALS CARRIED FORWARD FROM THE
BACK
7. AMOUNT CLAIMED (Total of cols. (f), (g) and (i).))
$
TOTALS
8. This claim is approved. Long distance telephone calls, if shown, are certified
10. I certify that this claim is true and correct to the best of my knowledge and
as necessary in the interest of the Government. (Note: If long distance calls
belief and that payment or credit has not been received by me.
are included, the approving official must have been authorized, in writing, by
Sign Original Only
the head of the department or agency to so certify (31 U.S.C. 680a).)
Sign Original Only
DATE
CLAIMANT
SIGN HERE
DATE
11.
CASH PAYMENT RECEIPT
a. PAYEE (Signature)
b. DATE RECEIVED
APPROVING
OFFICIAL
HERE
C. AMOUNT
9. This claim is certified correct and proper for payment.
Sign Original Only
$
AUTHORIZED
DATE
CERTIFYING
12. PAYMENT MADE
OFFICER
BY CHECK NO.
HERE
ACCOUNTING CLASSIFICATION
1164-210
STANDARD FORM 1164 (Rev.11-77)
Prescribed by GSA, FPMR (CFR 41) 101-7
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