5210/12 Firm Travel Voucher

OMB Number: 3064-0122

EXPIRATION DATE: 03/31/2007

Federal Deposit Insurance Corporation FIRM TRAVEL VOUCHER

SECTION I – TRAVELER INFORMATION

1. NAME OF TRAVELER (Last, First, MI)

2. HOME OFFICE

3. FEDERAL TAX ID NUMBER

4. INVOICE NUMBER

     

     

     (Last 4 digits)

     

5. RESIDENCE (Include City, State, and ZIP Code)

6. FIRM NAME

7. MATTER NUMBER

     

     

     

8. DATE

9. NATURE OF EXPENSE (Departure/Arrival Times are Required for Per Diem Payment)

AMOUNTS CLAIMED

10. Mileage

11. Per Diem

12. Lodging

13. Air Fare

14. Car Rental

15. Other

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

16. CONTINUATION SHEET (Subtotals brought forward)

     

     

     

     

     

     

17. TOTALS

     

     

     

     

     

     

18. CERTIFIED CORRECT (Traveler's Signature)

19. DATE SIGNED

20. TOTAL REIMBURSEMENT

     

     

NOTE: If additional space is needed, complete and attach form FDIC 5210/12A, Firm Travel Voucher (Continuation Sheet).

SECTION II – CERTIFICATION

I certify that I have examined this travel voucher and to the best of my knowledge and belief all costs claimed are allowable in accordance with FDIC travel regulations. Costs claimed here have not been previously billed to FDIC unless identified as a resubmission.

NAME/TITLE OF FDIC OVERSIGHT ATTORNEY

SIGNATURE

DATE

     

     

PRIVACY ACT STATEMENT The Financial Institutions Reform, Recovery and Enforcement Act of 1989, 12 U.S.C. Sec. 1441a, provides the authority to solicit the requested information, except for Social Security Number which is solicited under the authority of Executive Order 9397. The primary use of this information is to examine and approve reimbursement for expenses incurred on authorized travel by FDIC contractors. The information on this form may be disclosed to the General Accounting Office in connection with periodic audits, to Federal or State agencies charged with enforcing or implementing a statute, rule or regulation when it appears there may have been a violation of that statute, rule or regulation. Information on this form may also be disclosed as set forth in the routine uses in the FDIC's Financial Information System of records. Providing the information is voluntary; however, failure to provide all the requested information may result in suspension or disallowance of your travel expense claim.

PAPERWORK REDUCTION ACT NOTICE Public reporting burden for this collection of information is estimated to average 1.0 hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Paper Reduction Act Clearance Officer, Legal Division, Federal Deposit Insurance Corporation, 550 17th Street, N.W., Washington, DC 20429, and the Office of Management and Budget, Paperwork Reduction Project (3064-0122), Washington, D.C. 20503. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number

FDIC 5210/12 (3-06)