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    Claim For Reimbursement For Expenditures On Official Business

    Uploaded by

    MARSHA MAINES
    This document is a claim form for reimbursement of expenditures during official business. It requests information such as the claimant's name, address, employee ID number, dates and details of expenditures. Expenditures can include mileage, fares, tolls, and other miscellaneous expenses. The claimant certifies the claim is true and correct. An approving official also signs to approve payment. The form provides privacy act information stating the primary purpose is to determine reimbursement payments from the government.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Claim For Reimbursement For Expenditures On Official Business

    Uploaded by

    MARSHA MAINES
    121 views2 pages
    This document is a claim form for reimbursement of expenditures during official business. It requests information such as the claimant's name, address, employee ID number, dates and details of expenditures. Expenditures can include mileage, fares, tolls, and other miscellaneous expenses. The claimant certifies the claim is true and correct. An approving official also signs to approve payment. The form provides privacy act information stating the primary purpose is to determine reimbursement payments from the government.

    Original Description:

    HOW TO CLAIM YOUR COSTS FOR DOING GOVERNMENT EMPLOYEES JOBS FOR THEM

    Original Title

    OF1164-17b

    Copyright

    © © All Rights Reserved

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    This document is a claim form for reimbursement of expenditures during official business. It requests information such as the claimant's name, address, employee ID number, dates and details of expenditures. Expenditures can include mileage, fares, tolls, and other miscellaneous expenses. The claimant certifies the claim is true and correct. An approving official also signs to approve payment. The form provides privacy act information stating the primary purpose is to determine reimbursement payments from the government.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    121 views2 pages

    Claim For Reimbursement For Expenditures On Official Business

    Uploaded by

    MARSHA MAINES
    This document is a claim form for reimbursement of expenditures during official business. It requests information such as the claimant's name, address, employee ID number, dates and details of expenditures. Expenditures can include mileage, fares, tolls, and other miscellaneous expenses. The claimant certifies the claim is true and correct. An approving official also signs to approve payment. The form provides privacy act information stating the primary purpose is to determine reimbursement payments from the government.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    1. DEPARTMENT OR ESTABLISHMENT, BUREAU, DIVISION OR OFFICE 2.

    VOUCHER NUMBER
    CLAIM FOR REIMBURSEMENT
    FOR EXPENDITURES 3. SCHEDULE NUMBER
    ON OFFICIAL BUSINESS
    Read the Privacy Act Statement on the back of this form. 5. PAID BY
    4. a. NAME (Last, first, middle initial) b. EMPLOYEE ID NUMBER
    C
    L
    A
    I c. MAILING ADDRESS (Include ZIP Code) d. OFFICE TELEPHONE NUMBER
    M
    A
    N
    T
    6. EXPENDITURES (If fare or toll claimed in column (g) exceeds charge for one person, show in column (h) the number of additional persons which
    accompanied the claimant.)
    DATE
    C
    Show appropriate code in column (b):
    MILEAGE RATE AMOUNT CLAIMED
    A - Local Travel D. Funeral Honors Detail (Enter Whole
    O B - Telephone or Telegraph E. Specialty Care Numbers Only)
    D c
    C - Other expenses (itemized) FARE
    E (Explain expenditures in specific detail.) NUMBER OF OR ADD TIPS AND
    MILES MILEAGE TOLL PERSONS MISCELLANEOUS
    (a) (b) (c) FROM (d) TO (e) (f) (g) (h) (i)

    If additional space is required continue on the back. SUBTOTALS CARRIED FORWARD FROM THE
    BACK

    7. AMOUNT CLAIMED (Total of columns (f), (g) and (i).) $


    TOTALS
    8. This claim is approved. Long distance telephone calls, if shown, are certified as 10. I certify that this claim is true and correct to the best of my knowledge and belief
    necessary in the interest of the Government. (Note: If long distance calls are and that payment or credit has not been received by me.
    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).) Sign Original Only

    DATE
    CLAIMANT
    Sign Original Only SIGN HERE
    DATE 11. CASH PAYMENT RECEIPT
    APPROVING a. PAYEE (Signature) b. DATE RECEIVED
    OFFICIAL
    SIGN HERE
    9. This claim is certified correct and proper for payment. c. AMOUNT

    AUTHORIZED Sign Original Only $


    CERTIFYING DATE
    OFFICER 12. PAYMENT MADE
    SIGN HERE BY CHECK NUMBER

    ACCOUNTING CLASSIFICATION

    OPTIONAL FORM 1164 (REV. 11/2017)


    6. EXPENDITURES -- Continued
    DATE Show appropriate code in column (b): AMOUNT CLAIMED
    C A - Local Travel D. Funeral Honors Detail MILEAGE
    O B - Telephone or Telegraph E. Specialty Care RATE
    D C - Other expenses (itemized) c FARE
    E (Explain expenditures in specific detail.) NUMBER OF OR ADD TIPS AND
    MILES MILEAGE TOLL PERSONS MISCELLANEOUS
    (a) (b) (c) FROM (d) TO (e) (f) (g) (h) (i)

    Total each column and enter on the front, subtotal line.

    In compliance with the Privacy Act of 1974, the following information is provided: Solicitation of the information on this form is authorized by Executive Order 11609 of July 22, 1971, Executive Order 11012 of March
    27, 1962, Executive Order 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 of reimbursements from 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 employee, the
    issuance of a security clearance, or investigations of the performance of official duty while in Government service. An Employee Identification (ID) Number is solicited under the authority of the Internal Revenue
    Code (26 U.S.C. 6011(b) and 6109) and Executive Order 9397, November 22, 1943, for use as a taxpayer and/or identification number. Disclosure is MANDATORY on vouchers claiming payment or reimbursement
    which is, or may be, taxable income. Disclosure of your ID Number and other requested information is voluntary in all other instances. Failure to provide the information (other than ID Number) required to support
    the claim may result in delay or loss of reimbursement.

    OPTIONAL FORM 1164 (REV. 11/2017) BACK

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