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FOR EXPENDITURES ON OFFICIAL BUSINESS CLAIM FOR REIMBURSEMENT (Office of Surface Mining)

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5. PAID BY
DATE
MILEAGE
RATE
(Explain expenditures in specific detail.)
(c) FROM
(d) TO
NO. OF
MILES
(e)
(b)(a)
AMOUNT CLAIMED
MILEAGE
(f)
FARE
OR TOLL
(g)
ADD
PER-
SONS
(h)
TIPS AND
MISCEL-
LANEOUS
(i)
c. MAILING ADDRESS (Include ZIP Code)
b. SOCIAL SECURITY NO.
3. SCHEDULE NUMBER
Read the Privacy Act Statement on the back of this form.
a. NAME (Last, first, middle initial)
d. OFFICE TELEPHONE NUMBER
Sign Original Only
CLAIM FOR REIMBURSEMENT
FOR EXPENDITURES
ON OFFICIAL BUSINESS
1. DEPARTMENT OR ESTABLISHMENT, BUREAU, DIVISION OR OFFICE 2. VOUCHER NUMBER
If additional space is required continue on the back.
SUBTOTALS CARRIED FORWARD FROM THE
BACK
TOTALS
7. AMOUNT CLAIMED (Total of cols. (f), (g) and (i).)
$
10. I certify that this claim is true and correct to the best of my knowledge and
belief and that payment or credit has not been received by me.
Sign Original Only
ACCOUNTING CLASSIFICATION
APPROVING
OFFICIAL
SIGN HERE
DATE
DATE
CLAIMANT
SIGN HERE
9. This claim is certified correct and proper for payment.
Sign Original Only
DATE
11. CASH PAYMENT RECEIPT
a. PAYEE (Signature)
b. DATE RECEIVED
c. AMOUNT
12. PAYMENT MADE
BY CHECK NO.
STANDARD FORM 1164 (Rev. 11-77)
Prescribed by GSA, FPMR (CFR 41) 101-7
$
DoD Overprint 4/2002
C
O
D
E
APPROVING
OFFICIAL
SIGN HERE
Show appropriate code in col. (b):
A - Local travel
B - Telephone or telegraph, or
C - Other expenses (itemized)
D - Funeral Honors Detail
E - Specialty Care
This claim is approved. Long distance telephone calls, if shown, are certified as
necessary in the interest of the Government. (Note: If long distance calls are
included, the approving official must have been authorized in writing, by the head
of the department or agency to so certify (31 U.S.C. 680a).)
8.
20
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.)
4. CLAIMANT
xxxxxxxxxxxxxxxxxxx
18
OFFICE OF SURFACE MINING
DIVISION OF TECHNICAL TRAINING
In compliance with the Privacy Act of 1974, the following information is provided: Solicitation of the information on this form is authorize by the 5 U.S.C. Chapter 57 as implemented
by the Federal Travel Regulation (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 reimbursements to the Government. 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
employe, the issuance or a security clearance, or investigations of the performance of official duty while in Government service. Your Social Security Account Number (SNN) 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.
6. EXPENDITURES - Continued
DATE
20
(Explain expenditures in specific detail.)
(c)
FROM
(d) TO
(b)
(a)
AMOUNT CLAIMED
Total each column and enter on the front, subtotal line.
STANDARD FORM 1164 Back (Rev. 11-77)
DoD Overprint 4/2002
C
O
D
E
Show appropriate code in col. (b):
NO. OF
MILES
(e)
MILEAGE
RATE
MILEAGE
(f) (g)
FARE
OR TOLL
ADD
PER-
SONS
(h) (i)
TIPS AND
MISCEL-
LANEOUS
D - Funeral Honors Detail
E - Specialty Care
A - Local travel
B - Telephone or telegraph, or
C - Other expenses (itemized)
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FOR EXPENDITURES ON OFFICIAL BUSINESS CLAIM FOR REIMBURSEMENT (Office of Surface Mining)

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Completed 10 August 2020

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