Form xxxx HP Travel Reimbursement Form

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OMB Number: 11050030

Expires 07/31/2016

U.S. Department of Justice

Honors Program Reimbursement Form

PLEASE RETURN THIS FORM WITHIN 2 WEEKS OF THE INTERVIEW
Name: ______________________________________________

Social Security Number: ___________________

Mailing Address: ______________________________________
______________________________________
______________________________________

E-Mail: _________________________________
Telephone: ______________________________
FAX: ___________________________________

Traveled From: _______________ To: ________________ Round Trip? Yes
From: _______________ To: ________________ Round Trip? Yes
From: _______________ To: ________________ Round Trip? Yes

No Travel Dates: _______ to _______
No Travel Dates: _______ to _______
No Travel Dates: _______ to _______

Payment will be issued by electronic fund transfer. Please provide the following information on your checking or savings
account:
•

ABA Routing Number (On a checking account, this is a nine-digit number on the bottom, left side of a check. Ask
your bank if you have questions). __________________

•

Your bank account number: ________________________

Checking or

Savings

EXPENSES CLAIMED (Receipts are required for expenses over $75.00.)
Do not claim food purchases; you will receive M&IE if your travel exceeded 12 hours. See the Travel Memo at
http://www.justice.gov/careers/legal/hptvmemo.html for details.
TYPE

DATE(S)

AMOUNT

Lodging (receipt required)
Lodging Tax
Taxi (Only if pre-authorized or specifically approved due to late flight, etc)
Mileage (If travel by private auto was authorized) Reimbursement is limited to the mileage
rate at the time of travel. See www.gsa.gov for details.

Total miles:

Taxi Cabs (Only if pre-authorized or specifically approved due to late flight, etc)
Parking/Fare/Toll (Include Metrorail, train, etc. Do not include prepaid air/rail fare.)
Miscellaneous: Itemize below. Airline baggage charges will not be reimbursed.

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.
Signature: ____________________________________ Date: ___________________
Please fax back to the attention of your scheduler at 202-307-0862
PRIVACY ACT STATEMENT (This information is provided pursuant to the Privacy Act of 1974, 5 U.S.C.§552a(e)(3)): This form
requests personal information that is relevant and necessary for reimbursing expenses incurred during your travel for your interview(s) with
components participating in the Attorney General's Honors Program. DOJ collects this information in order to reimburse authorized
expenses. OARM has the authority to ask for this information pursuant to 5 U.S.C. §301, and 28 C.F.R. Part 0.15(b)(2). Because accepting
reimbursement for travel expenses is voluntary, you are not required to provide any personal information; however, failure to provide this
information could result in your not receiving reimbursement for your travel expenses.

DOJ USE ONLY:
APPROVED ___________________________________ DATE _________________