TRAVEL VOUCHER
(Read the Privacy Act Statement
on the back)
a.
DIFFERENCES,
IF ANY
(Explain and
show amount)
b. TO
b. DATE(S)
f. RESIDENCE (City and State)
2. TYPE OF TRAVEL 3. VOUCHER NUMBER
12. GOVERNMENT
TRANSPORTATION
REQUESTS, OR
TRANSPORTATION
TICKETS, IF PURCHASED
WITH CASH
(List by number below and
attach passenger coupon; if
cash is used show claim on
reverse side.)
NOTE: Falsification of an item in an expense account works a forfeiture of claim (28 U.S.C. 2514) and may result in a fine of not more than $10,000 or
imprisonment for not more than 5 years or both (18 U.S.C. 287; i.d. 1001).
e. PRESENT DUTY STATION
a. NAME (Last, First, Middle Initial)
c. PAYEE’S SIGNATURE
4. SCHEDULE NUMBER
6. PERIOD OF TRAVEL
MODE, CLASS OF
SERVICE, AND
ACCOMMODATIONS
(c)
NET TO TRAVELER
7. TRAVEL AUTHORIZATION
9. CASH PAYMENT RECEIPT
d. OFFICE TELEPHONE
NUMBER
a. FROM
b. SOCIAL SECURITY NUMBER
c. Amount due Government
Attached:
b. AMOUNT RECEIVEDa. DATE RECEIVED
a. Outstanding
d. Balance outstanding
b. Amount to be applied
5.
T
R
A
V
E
L
E
R
(P
A
Y
E
E)
POINTS OF TRAVEL
TO
(f)
1. DEPARTMENT OR ESTABLISHMENT,
BUREAU, DIVISION, OR OFFICE
I hereby assign to the United States any right I may have against any parties in connection with reimbursable
transportation charges described below.
ISSUING
CARRIER
(Initials)
(b)
AGENT’S
VALUATION
OF TICKET
(a)
DATE
ISSUED
(d)
FROM
(e)
Traveler’s Initials
c. MAILING ADDRESS (Include ZIP Code)
10. CHECK NUMBER
AUTHORIZED
CERTIFYING
OFFICIAL
SIGN HERE
14. This voucher is approved. Long distance telephone calls, if any, are certified as
necessary in the interest of the Government. (NOTE: If long distance telephone 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).)
DATE
c. MONTH AND YEAR
13. I certify that this voucher is true and correct to the best of my knowledge and belief, and that payment or credit has not been received
by me. When applicable, per diem claimed is based on the average cost of lodging incurred during the period covered by this voucher.
TRAVELER
SIGN HERE
DATE
8. TRAVEL ADVANCE
15. LAST PRECEDING VOUCHER PAID UNDER SAME TRAVEL AUTHORIZATION
APPROVING
OFFICIAL
SIGN HERE
AMOUNT
CLAIMED
DATE
a. NUMBER(S)
a. VOUCHER NUMBER b. DISBURSING OFFICE SYMBOL
16. THIS VOUCHER IS CERTIFIED CORRECT AND PROPER FOR PAYMENT
17. FOR FINANCE OFFICE USE ONLY
COMPUTATION
11. PAID BY
c. APPLIED TO TRAVEL ADVANCE
(Appropriation symbol):
b. TOTAL VERIFIED CORRECT FOR
CHARGE TO APPROPRIATION
Certifier’s Initials:
18. ACCOUNTING CLASSIFICATION
OPTIONAL FORM 1012 (REV. 10/2016)
PERMANENT
CHANGE OF STATION
TEMPORARY DUTY
Cash
Check
US Arctic Research Commission
Doe, John
123-45-6789
1234 Elm Street
Washington, DC 12345
(555)555-5555
Washington, DC
Arlington, VA
01/07/2019
01/11/2019
$1,206.23
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit
Complete this information if this is a
continuation sheet.
SCHEDULE
OF
EXPENSES
AND
AMOUNTS
CLAIMED
INSTRUCTIONS TO TRAVELER (Unlisted items are self-explanatory)
Column (c): If the voucher includes
per diem allowances for members
of employee’s immediate family,
show member’s names, ages, and
relationship to employee and
marital status of children (unless
information is shown on the travel
authorization.)
Complete only for
actual expense
travel
Column (d) thru (g) Show amount incurred for each meal, including tax and tips, and daily total meal
cost.
(h) Show expenses, such as laundry, cleaning and pressing of clothes, tips to bellboys, porters, etc.
(other than for meals).
(i) Complete for per diem and actual expense travel.
(j) Show total subsistence expense incurred for actual expense travel.
(m) Show per diem amount, limited to maximum rate, or if travel on actual expense, show the lesser of
the amount from column (j) or maximum rate.
(n) Show expenses, such as taxi/limousine fares, air fare (if purchased with cash), local or long
distance telephone calls for Government business, car rental, relocation other than subsistence,
etc.
PAGES
TRAVELER’S LAST NAME
OF
PAGE
TRAVEL AUTHORIZATION NUMBER
MEALS
/
TIME
(Hour and
am/pm)
(b)
DESCRIPTION
(Departure/arrival city, per diem computation,
or other explanations of expense)
(c)
AMOUNT CLAIMED
ITEMIZED SUBSISTENCE EXPENSES
c
DATE
(a)
MILEAGE
RATE:
LUNCH
(e)
Enter the total of columns (l), (m), and (n) below and
in item 13 on the front of this form.
BREAKFAST
(d)
MISCELLANEOUS
SUBSISTENCE
(h)
DINNER
(f)
NUMBER
OF MILES
(k)
TOTAL
(g)
OTHER
(n)
LODGING
(i)
MILEAGE
(l)
SUBSISTENCE
(m)
TOTAL
SUBSISTENCE
EXPENSE
(j)
If additional space is required, continue on another Optional Form 1012 BACK, leaving the front blank.
TOTALS
TOTAL
AMOUNT
CLAIMED
OPTIONAL FORM 1012 (REV. 10/2016) BACK
In compliance with the Privacy Act of 1974, the following information is provided: Solicitation of the information on this form is authorized by 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 relocation expenses incurred under appropriate administrative authorization and to record and maintain costs of such reimbursements to
the Government. The information will be used by 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 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 tax
payer and/or employee identification number; disclosure is MANDATORY on vouchers claiming travel and/or relocation allowance expense 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 proved the information (other than SSN) required to support the
claim may result in delay or loss of reimbursement.
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Home to IAD
30.0
58.0
IAD to LAX/cab to hotel
$36.00
LA/phone/bag & package handling
$75.00
$7.00
$5.00
LA/rental car
$100.00
$125.00
LA/rental car fuel
$100.00
$27.93
LA/meeting registration
$100.00
$305.00
LA/tips/laundry/ATM fee
$100.00
$20.00
$7.50
LA/LAX to IAD/airport shuttle
$75.00
$18.00
Parking at IAD/IAD to home
30.0
$45.00
Luggage fee
$25.00
2019
$1,206.23
$17.40
$17.40
$34.80
$577.00
$594.43
$82.00
$100.00
$100.00
$100.00
$120.00
$75.00
$82.00
$100.00
$100.00
$100.00
$120.00
$75.00
$75.00
$100.00
$100.00
$100.00
$100.00
$75.00