OMB Number: 3064-0122
EXPIRATION DATE: 12/31/2019
FDIC 5210/12 (3-06)
Federal Deposit Insurance Corporation
FIRM TRAVEL VOUCHER
SECTION I – TRAVELER INFORMATION
1. NAME OF TRAVELER (Last, First, MI) 2. HOME OFFICE 3. FEDERAL TAX ID NUMBER 4. INVOICE NUMBER
5. RESIDENCE (Include City, State, and ZIP Code) 6. FIRM NAME 7. MATTER NUMBER
AMOUNTS CLAIMED
8. DATE
9. NATURE OF EX
PENSE
(Departure/Arrival Times are Required for Per Diem Payment)
10. Mileage
11. Pe
r
Diem 12. Lodging
13. Air
F
are
14. C
a
r
R
ent
al 15. Other
16. CONTINUATION SHEET (Subtotals brought forward)
17. TOTALS
18. CERTIFIED CORRECT (Traveler's Signature) 19. DATE SIGNED 20. TOTAL REIMBURSEMENT
NOTE: If additional space is needed, complete and attach form FDIC 5210/12A, Firm Travel Voucher (Continuation Sheet).
SECTION II – CERTIFICATION
I certify that I have examined this travel voucher and to the best of my knowledge and belief all costs claimed are allowable in accordance with
FDIC travel regulations. Costs claimed here have not been previously billed to FDIC unless identified as a resubmission.
NAME/TITLE OF FDIC OVERSIGHT ATTORNEY SIGNATURE DATE
PRIVACY ACT STATEMENT
The Financial Institutions Reform, Recovery and Enforcement Act of 19
89, 12 U.S.C. Sec. 1441a, provides the authority to solicit the requested information, except
for Social Security Number which is solicited under the authority
of Executive Order 9397, as amended. The primary use of this information is to examine and approve
reimbursement for expenses incurred on authorized travel by FDIC contractors. The info
rmation on this form may be disclosed to the General Accounting Office in
connection with periodic audits, to Federal or State agencies charged with enforcing or implementing a statute, rule or regulation wh
en it appears there may have been
a violation of that statute, rule or regulation. Information on this form may also be disclosed as set forth in the routine uses in the FDIC
's Financial Information System
of records. Providing the information is voluntary; however, failure to provide all the requested information may result in suspension or disa
llowance of your travel
expense claim.
PAPERWORK REDUCTION ACT NOTICE
Public reporting burden for this collection of information is estimated to average 1.0
hour per response, including the time for reviewing instructions, searching existing
data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate
or any other aspect of this collection of information, including suggestions for reducing this burden, to the Paper Reduction Act Clearance Officer, Legal Division,
Federal Deposit Insurance Corporation, 550 17
th
Street, N.W., Washington, DC 20429, and the Office of Management and Budget, Paperwork Reduction Project
(3064-0122), Washington, D.C. 20503. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it
displays a currently valid OMB control number
