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 A-E TRAVEL CLAIM VOUCHER
NAME
FIRM
PLACE OF TRIP
PURPOSE OF TRIP
AUTHORIZED BY
DATE
ITINERARY
DATE
LOCAL TIME
(Home, Office, Base, Activity,
MODE OF
(24 Hour Clock)
City and State, City
TRAVEL
19
and Country etc)
DEP
ARR
DEP
ARR
DEP
ARR
DEP
ARR
DEP
ARR
DEP
ARR
REIMBURSABLE EXPENSES
CAR RENTAL
$
CAR PARKING
$
PRIVATE CAR MILEAGE(.29/MILE)
$
I CERTIFY THAT AMOUNTS ARE ACTUAL AND NECESSARY
BRIDGE, ROAD, FERRY TOLLS
$
EXPENSES INCURRED IN PERFORMANCE OF OFFICIAL
GASOLINE
$
TRAVEL FOR WHICH I HAVE NOT BEEN REIMBURSED:
TAXI
$
AIR FARE
$
(SIGNATURE)
DATE
REQUIRED ATTACHMENTS: A. RECEIPTS FROM CARRIERS, COPIES OF TICKETS, OR REQUIRED CERTIFICATIONS IF COST
OF TRANSPORTATION IS CLAIMED.
B. RECEIPTS FOR LODGINGS AND ANY ITEM OF EXPENSE CLAIMED IN EXCESS OF $25.00.
C. ITEMIZATION OF ACTUAL EXPENSES ON A DAILY BASIS WHEN CLAIM FOR REIMBURSEMENT INCLUDES
TRAVEL ON AN ACTUAL EXPENSE BASIS.
INFORMATION REQUIRED BY THE PRIVACY ACT OF 1974. AUTHORITY: 5 U.S.C. 5701-5742.37 U.S.C. 404-427, AND E.O. 9397 PRINCIPLE
PURPOSE: USED FOR REVIEWING, APPROVING, ACCOUNTING AND DISBURSING FOR OFFICIAL TRAVEL.
ROUTINE USES: TO SUBSTANTIATE CLAIMS FOR REIMBURSEMENT FOR OFFICIAL TRAVEL.
DISCLOSURE: VOLUNTARY. FAILURE TO FURNISH INFORMATION REQUESTED MAY RESULT IN TOTAL OR PARTIAL DENIAL OF CLAIM.
Exhibit 10-C
199
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