7. TRAVEL AUTHORIZATION
(Read the Privacy Act
Statement on the
1. DEPARTMENT OR ESTABLISHMENT,
BUREAU, DIVISION, OR OFFICE
2. TYPE OF TRAVEL
3. VOUCHER NO.
4. SCHEDULE NO.
a. NAME (Last, first, middle initial)
c. MAILING ADDRESS (Include ZIP Code)
e. PRESENT DUTY STATION
b. SOCIAL SECURITY NUMBER
d. OFFICE TELEPHONE NO.
6. PERIOD OF TRAVEL
f. RESIDENCE (city and State)
10. CHECK NO.
8. TRAVEL ADVANCE
9. CASH PAYMENT RECEIPT 11. PAID BY
b. Amount to be applied
c. Amount due Government
d. Balance outstanding
c. PAYEE'S SIGNATURE
TICKETS, IF PUR-
CHASED WITH CASH
(List by number below
and attached passenger
coupon; if cash is used
show claim on reverse
I hereby assign to the United States any right I may have against any parties in connection with reimbursable
transportation charges described below, purchased under cash payment procedures (FPMR 101-7).
POINTS OF TRAVEL
a. DATE RECEIVED
b. AMOUNT RECEIVED
13. I certify that this voucher is true and correct to the best of my knowledge and belief, and that payment or credit has not
been received by me. When applicable, per diem claimed is based and the average cost of lodging incurred during the period
covered by this voucher.
NOTE; Falsification of an item in an expense account works a forfeiture of claim (27 U.S.C. 2514) and may result in a fine
of not more than $10,000 or imprisonment for not more than 5 years or both (18 U.S.C. 287; i.d. 1001).
14. This voucher is approved. Long distance telephone calls, if any, are certified as necessary
in the interest of the Government. (NOTE: If long distance telephone 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).
17. FOR FINANCE OFFICE USE ONLY
15. LAST PRECEDING VOUCHER PAID UNDER SAME TRAVEL AUTHORIZATION
a. VOUCHER NO. b. D.O. SYMBOL c. MONTH &
16. THIS VOUCHER IS CERTIFIED CORRECT AND PROPER FOR PAYMENT
18. ACCOUNT CLASIFICATION
b. TOTAL VERIFIED CORRECT FOR
CHARGE TO APPROPRIATION
c. APPLIED TO TRAVEL ADVANCE
d. NET TO TRAVELER
STANDARD FORM 1012 (REV. 10-77)
Prescribed by GSA, FPMR (41 CFR) 101-7
5. TRAVELER (PAYEE)