Fillable Phs-2988 FORM PHS-2988

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Phs-2988 FORM PHS-2988

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
VOUCHER FOR REIMBURSEMENT FOR TRAVEL
DEPENDENTS OF PHS COMMISSIONED OFFICERS
D.O. VOUCHER NO. BUREAU VOUCHER NO.
AGENCY DIVISION/ BUREAU/CENTER /AREA OFFICE
PAYEE (Full Name)
SOCIAL SECURITY NUMBER
PAID BY
MAILING ADDRESS (Include Zip Code)
OFFICIAL DUTY STATION P.O. NO. DATE OF P.O.
CERTIFICATION OF CLAIMANT
Payment is requested for travel by persons listed below who were my dependents on the effective date of applicable orders or other authority. Travel
was performed with the intent of establishing a bona-fide residence. (If any of the dependents claimed are other than a lawful spouse or unmarried
legitimate child(ren) under 21 years of age, complete the appropriate certificate on the reverse.)
FULL NAME RELATIONSHIP TO OFFICER BIRTH DATE OF CHILDREN
LOCATION OF DEPENDENTS (On date of receipt of order/authority - Street, City, State, Zip Code)
DATE OF DEPARTURE
DESIGNATED DESTINATION OF DEPENDENT(S) (Street, City, State, Zip Code)
DATE OF ARRIVAL
NOTE: (When travel is from other than the vicinity of the old station or other than the vicinity of the new station, explain circumstances on the reverse.)
GOVERNMENT TRANSPORTATION FURNISHED
MODE OF TRAVEL (Rail, air, etc. If none, so state) T.R. NO. (If used, attached copy)
PLACE OF DEPARTURE DATE
DESTINATION
DATE OF ARRIVAL
TRAVEL COVERED BY THIS CLAIM REPRESENTS ENTIRE TRAVEL OF ALL MY DEPENDENTS ON THIS CHANGE OF STATION EXCEPT
PENALTY FOR PRESENTING FRAUDULENT CLAIM - Fine of not more than $10,000 or imprisonment for not more than 5 years or both.
(Title 18, U.S.C. 287, id. 1001)
FORFEITURE OF FRAUDULENT CLAIM - Falsification of an item an expense account will forfeit the claim.
(Title 28, U.S.C. 2514)
CERTIFICATION SIGN ORIGINAL ONLY
I certify that this voucher and attachments are correct and payment has not been received. No prior claim has been presented by me or any member of
my family for the travel of dependents as claimed herein.
SIGNATURE OF PAYEE
DATE
AUTHORIZED ALLOWANCE
DATE (From) DATE (To)
DISLOCATION ALLOWANCE
Yes
No
AMOUNT
$
MILEAGE
APPROVED FOR
ACCOUNTING CLASSIFICATION (Appropriations Symbol must be shown; other classification optional.)
PHS-2988 (Rev. 11/16)
PSC Publishing Services (301) 443-6740
EF
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CERTIFICATE OF DEPENDENCY
A certificate of dependency is required for a dependent spouse; dependent natural, step, and adopted children; dependent parents; dependent children
over 21 years of age who are mentally or physically incapacitated; and unmarried dependent children who are under 23 years of age and are or will be
attending a school in the United States for the purpose of obtaining a secondary or undergraduate college education.
CERTIFICATE OF PROOF OF DEPENDENCY
I CERTIFY that my dependent(s)
(Relationship)
named in this claim (reverse side)
is /are in fact dependent upon me and that evidence of dependency has been filed on appropriate forms and accepted by proper authority.
NOTE: In case of a dependent parent,the certificate of dependency must be approved annually.
SIGNATURE OF OFFICER
DATE
ADDITIONAL CERTIFICATE OF RESIDENCE OF PARENT
I CERTIFY that my dependent(s)
(Relationship)
resided as a member of my
household at the time of receipt of applicable orders other authority and resided as a member of my household established incident to the change
of station.
SIGNATURE OF CLAIMANT DATE
ADDITIONAL CERTIFICATE FOR STEPCHILD(REN)
I CERTIFY that
(Mother’s/Father’s Name)
, the mother/father of the stepchild(ren)
named in this claim was my legal spouse at the time this travel was performed.
SIGNATURE OF CLAIMANT
DATE
ADDITIONAL INFORMATION (This space may be used by claimant for any additional information which is necessary in settlement of this claim.)
Privacy Act Statement for
Voucher for Reimbursement for Travel
Dependents of PHS Commissioned Officers
Form PHS-2988
This statement is provided pursuant to the Privacy Act of 1974 (5 U.S.C. 552a). Our authority to collect this information is 37 U.S.C. 403; 42 U.S.C. 202
et seq.; and Executive Order 9397, "Numbering System for Federal Accounts Relating to Individual Persons."
The information provided is used to certify the dependency status of the persons for whom travel reimbursement is requested. The other uses which
may be made of this information are described in the system notice for records system 09-37-0002, "PHS Commissioned Corps General Personnel
Records, HHS/OASH/OSG." A copy of this system notice may be obtained from the office to which you submit this form.
Disclosure of Social Security Number (SSN) is mandatory. The SSN is requested for identification purposes. Failure to supply complete and accurate
information may result in denial of request.
PHS-2988 (Rev. 11/16) (BACK)
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Phs-2988 FORM PHS-2988

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Completed 27 February 2020

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