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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LA/phone/bag & package handling
LA/LAX to IAD/airport shuttle
Parking at IAD/IAD to home
