Claim for reinbursement for expenditures




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CLAIM FOR REINBURSEMENT
FOR EXPENDITURES
ON OFFICIAL BUSINESS


1.DEPARTMENT OR ESTABLISHMENT, BUREAU, DIVISION OR OFFICE

2. VOUCHER NUMBER

NAVMED Accessions Program Manager, BUMED-DET

Bldg. 1, Floor 13, Room 13154

8901 Wisconsin Avenue

Bethesda, MD 20889-5611


N3185B15RV _ _ _ _ _

3. SCHEDULE NUMBER

     

Read the Privacy Act Statement on the back of this form.

5. PAID BY

4.

a. NAME (Last, first, middle initial)

b. SOCIAL SECURITY NO

     







N/A







c. MAILEING ADDRESS (Include ZIP Code)

d. OFFICE TELEPHONE NUMBER










6. EXPENDITURES

(If fare claimed in col. (g) exceeds charge for one person, show in col. (h) the number of additional persons which accompanied the claimant.)

DATE




Show appropriate code in col. (b):

MILEAGE

AMOUNT CLAIMED






A - Local travel
B - telephone or telegraph, or
C - Other expenses (Itemized)

RATE







ADD

TIPS AND

YR

    

  



MILEAGE

FARE

PER-

MISCEL-




(Explain expenditures in specific detail.)

NO OF
MILES




OR TOLL

SONS

LANEOUS

(a)

(b)

(c) FROM

(d) TO

(e)

(f)

(g)

(h)

(i)

     

 

     

     

     

    

  

    

  

   

   

  

     

     

 

     

     

     

    

  

    

  

   

   

  

     

     

 

     

     

     

    

  

    

  

   

   

  

     

     

 

     

     

     

    

  

    

  

   

   

  

     

     

 

     

     

     

    

  

    

  

   

   

  

     

     

 

     

     

     

    

  

    

  

   

   

  

     

     

 

     

     

     

    

  

    

  

   

   

  

     

     

 

     

     

     

    

  

    

  

   

   

  

     

     

 

     

     

     

    

  

    

  

   

   

  

     

     

 

     

     

     

    

  

    

  

   

   

  

     

If additional space is required continue on the back

SUBTITALS CARRIED FORWARD FROM THE

     

    

  

    

  

   

   

  

BACK

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

     


TOTALS

     







    

  

   

   

  

8.

This claim is approved. Long distance telephone calls, if shown, are certified
as necessary in the interest of the Government. (Note. If long distance 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).)


10.

I certify that this claim is true and correct to the best of my knowledge and
belief and that payment or credit has not been received by me.

Sign Original Only

Sign Original Only




DATE




CLAIMANT
SIGN HERE





     FORMTEXT       




DATE

11.

CASH PAYMENT RECEIPT

APPPROVING
OFFICIAL
SIGN HERE








a. PAYEE (signature)

b. DATE RECEIVED

     




     

9. This claim is certified correct and proper for payment.







c. AMOUNT

AUTHORIZED
CERTIFYING
OFFICER
SIGN HERE


Sign Original Only







$

     




DATE

12. PAYMENT MADE




     

BY CHECK NO.

     

ACCOUNTING CLASSIFICATION










(TO BE COMPLETED BY APPROVING OFFICIAL ALONG WITH BLOCK 2)





STANDARD FORM 1164 (Rev. 11-77)




6. EXPENDITURES - Continued

DATE




Show appropriate code in col. (b):

MILEAGE

AMOUNT CLAIMED






A - Local travel
B - telephone or telegraph, or
C - Other expenses (Itemized)

RATE







ADD

TIPS AND

YR

    

  



MILEAGE

FARE

PER-

MISCEL-




(Explain expenditures in specific detail.)

NO OF
MILES




OR TOLL

SONS

LANEOUS

(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 5 U.S.C Chapter 57 as implemented by the Federal Travel Regulations (FPMR 101-7), E.O. 11609 of July 22, 1971, E.O. 11012 of March 17 1962, E.O. 9397 of November 22, 1943, and 26 U.S.C. 601(b) and 6109. The primary purpose of the requested information is to determine payment or reimbursement to eligible individuals for allowable travel and/or other expenses incurred under appropriate administrative authorization and to record and maintain costs of such reimbursements to 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. Your Social Security Account 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 taxpayer and/or employee identification number; disclosure is MANDATORY on vouchers claiming payment or 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.

STANDARD FORM 1164 (REV. 11-77) BACK


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