AO 1012 (Rev. 11/06) 4. TRAVELER (PAYEE) TRAVEL VOUCHER 2. TYPE OF TRAVEL TEMPORARY DUTY PERMANENT CHANGE OF STATION , 5. PERIOD OF TRAVEL a. FROM b. TO d. OFFICE TELEPHONE NO. a. NAME (Last, first, middle initial) 3. VOUCHER NUMBER b. SOCIAL SECURITY NO. 1. OFFICE OR COURT UNIT 6. TRAVEL AUTHORIZATION , c. MAILING ADDRESS (Include ZIP Code) a. NUMBER(S) e. PRESENT DUTY STATION b. DATE(S) f. RESIDENCE (City and State) 7. TRAVEL ADVANCE 8. OPTIONAL USE e. What are the numbers of the travel advances being repaid at this time? a. Total of all Outstanding Advances b. Amount to be applied for this trip c. Amount Repaid Government Attached: Check Cash d. Balance Outstanding Travel Advance Numbers This information will be provided by the finance office. 9. TRANSPORTATION TICKETS List by number below and attach passenger coupon. If paid by the traveler show claim on the reverse side. 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). DATE ISSUED a. TOTAL COST b. AMOUNT CHARGED TO GTA (Centrally Billed Account) d. AMOUNT PAID BY TRAVELER c. POINTS OF TRAVEL FROM e. TO f. 10. I certify that the purpose of this trip was official business and, further, that this claim for reimbursement of travel expenses is true and correct to the best of my knowledge and belief; further, I have not received any other payment or credit for the travel expenses claimed on this voucher. TRAVELER SIGN HERE AMOUNT CLAIMED DATE $ NOTE: Falsification of an item on an expense account causes a forfeiture of claim (28 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). 11. I have reviewed this travel voucher and the expenses claimed appear reasonable and in compliance with the judiciary supporting personnel travel policies. VOUCHER REVIEWER SIGN HERE a. DIFFERENCES IF ANY (Explain and show amount) DATE 12. I approve the business purpose of this trip(s) and reimbursement for the amount claimed appears reasonable. APPROVING OFFICIAL SIGN HERE 14. ACCOUNTING CLASSIFICATION: 13. FOR FINANCE OFFICE USE ONLY FUND BUD ORG $ c. APPLIED TO TRAVEL ADVANCES DATE FY b. TOTAL VERIFIED CORRECT FOR CHARGE TO APPROPRIATION $ d. NET TO TRAVELER COST ORG PROGRAM BOC SUB 02 SUB 03 SUB 04 SUB 05 American LegalNet, Inc. www.FormsWorkflow.com SCHEDULE OF EXPENSES AND AMOUNTS CLAIMED DATE (a) TIME (Hour and am/pm) (b) INSTRUCTIONS TO TRAVELER (Unlisted items are self-explanatory) Col. (c) If the voucher includes per Complete Col. (d-f) only diem allowances for members (g) for of employee's immediate (h) actual family, show members' names, expense ages and relationship to (i) travel employee and martial status of children (unless information (j) is shown on the travel (m) authorization.) See Guide, Vol 1, CH VI for more information. (n) DESCRIPTION (Departure/Arrival city, per diem computation, or other explanations of expense) (c) MEALS BREAKFAST (d) LUNCH (e) DINNER (f) TOTAL (g) MISC. SUBSISTENCE (h) If additional space is required, continue on another AO 1012-A, BACK, leaving the front blank. LODGING (i) TOTAL SUBSISTENCE NO. OF EXPENSE MILES (j) (k) OF PAGES TRAVEL AUTHORIZATION NO. TRAVELER'S LAST NAME MILEAGE RATE: ITEMIZED SUBSISTENCE EXPENSES PAGE Complete information if this is a continuation sheet. Show amount incurred for each meal, including taxes and tips, relating to the meal being itemized. By calendar day, total the daily cost of meals. By calendar day, show the daily cost of incidentals, such as tips for maid services, forgotten items (eg., toothbrush), etc. Show the daily lodging cost excluding taxes for claims under actual expense method or per diem method. Show total subsistence expense incurred for actual expense travel. Show locality per deim amount or total of lodging plus M & IE rate if required by authorization, or total of actual expenses not to exceed the applicable maximum rates. Show other expenses such as local transportation (fares for bus, taxi, limousine, or subway, etc.) offical telephone calls, baggage handling, car rental, or relocation expenses other than subsistence. AMOUNT CLAIMED MILEAGE (l) SUBSISTENCE (m) OTHER (n) SUBTOTALS TOTALS Enter grand total of columns (l), (m), and (n), below and in Item 10 on the front of this form. TOTAL AMOUNT CLAIMED American LegalNet, Inc. www.FormsWorkflow.com