5210/12A Firm Travel Voucher (continuation sheet)

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OMB NUMBER: 3064-0122
EXPIRATION DATE: 07/31/201

Page

Federal Deposit Insurance Corporation

of

.

LAW FIRM TRAVEL VOUCHER
(Continuation Sheet)
1. NAME OF TRAVELER (Last, First, MI)

5. DATE

2. HOME OFFICE

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

3. FEDERAL TAX ID NUMBER

7. Mileage

8. Per Diem

4. INVOICE NUMBER

AMOUNTS CLAIMED
9. Lodging
10. Air
Fare

11. Car
Rental

12. Other

13. CONTINUATION TOTALS (This page only)
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, D.C. 20429, and the Office of Management and Budget, Paperwork Reduction Project (30640122), 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 5210/12A (3-06)