SCHEDULE
OF
EXPENSES
AND
AMOUNTS
CLAIMED
TIME
DATE
(Hour
19
and
am/pm)
(a) (b)
INSTRUCTIONS TO TRAVELER
Col. (c) If the voucher includes
per diem allowances for
members of employee's
immediate family, show
members' names, ages,
and relationship to em-
ployee and marital status
of (unless infor-
mation is shown on the
travel authorization.)
DESCRIPTION
ITEMIZED SUBSISTENCE EXPENSES
MILEAGE
AMOUNT CLAIMED
(Departure/arrival city, per diem
computation, or other explanations
of expense)
BREAK-
MEALS
MISCEL-
LANEOUS
SUBSIS- TOTAL NO. OF
RATE:
C
MILEAGE SUBSISTENCE OTHER
FAST
LUNCH DINNER TOTAL LODGING
TENCE SUBSISTENCE MILES
(c) (d) (e) (f) (g) (h) (i) (j) (k) (l) (m) (n)
Com-
plete
only
for
actual
expense
travel
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,
(Unlisted items are self-explanatory)
Col. (d) Show amount incurred for each meal, including tax and tips, and daily total
}
thru (g) 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 col. (i) 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.
If additional space is required continue on another SF-1012-A BACK, leaving the front blank.
SUBTOTALS
TOTALS
In compliance with the Privacy Act of 1974, the following information is pro-
criminal, or regulatory investigations or prosecutions, or when pursuant to a
vided. Solicitation of the information on this form is authorized by 5 U.S.C.
requirement by this agency in connection with the hiring or firing of an
Chap. 57 as implemented by the Federal Travel Regulations (FPMR 10-7),
employee, the issuance of a security clearance, or investigations of the per-
E.O. 11609 of July 22, 1971, E.O. 11012 of March 27, 1962, E.O. 9397 of
formance of official duty while in Government service. Your Social Security
November 22, 1943, and 26 U.S.C. 6011 (b) and 6109. The primary purpose
Account Number (SSN) is solicited under the authority of the Internal
Revenue Code (25 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 provide the information (other than SSN) required to
support the claim may result in delay or loss of reimbursement.
Complete this
PAGE
information
if this is a
continuation
OF
sheet.
PAGES
TRAVEL AUTHORIZATION NO.
TRAVELER'S LAST NAME
Enter grand total of columns (l), (m) and
(n), below and in item 13 on the front of
this form.
TOTAL
AMOUNT
CLAIMED
STANDARD FORM 1012 BACK (10-77)
