Form TSA Form 35## (#/1 TSA Form 35## (#/1 LEO Reimbursement Request-Invoice

Department of Homeland Security Transportation Security Administration LEO Reimbursement Request-Invoice
INSTRUCTIONS: This form is to be submitted monthly by participants of the Law Enforcement Officer (LEO) Reimbursement Program (LRP). An invoice is required for each Period of Performance for which payment is sought. All submissions must be accompanied by supporting documentation demonstrating actual cost/outlay for services provided (e.g.. payroll report, ledger, etc.). The completion of Section VI and/or the submission of checkpoint logs, timesheets, etc. are not a substitute for documentation of actual cost. Completion of all fields is required. LEO Reimbursement Program Invoices must be submitted to the local TSA Federal Security Director (FSD) for signature. FSD’s must forward approved invoices to the LRP office for final certification and payment. FSD Certified Invoices shall be emailed or faxed as follows: Eastern Regions 1&2 (lrp-efax-east@tsa.dhs.gov or 703-603-3007; Central Regions 3&4 (lrp-efax central@tsa.dhs.gov or 703-603-3010); Western Regions 5&6 (lrp-efax-west@tsa.dhs.gov or 703-603-3009). NOTE: Completed LEO Reimbursement Request-Invoices must be stored in locked filing cabinets.
SECTON I. INVOICE INFORMATION
Other Transaction Agreement Number:						Invoice Date:
Airport Name:						Airport Code:
DUNS Number:				Cage Code:		Invoice Number:
TINS Number:						(Each submission requires unique invoice number.)
SECTON II. INVOICING POINT OF CONTACT INFORMATION
Name:
Address:
Street					City		State		Zip Code
Phone No.:				Fax No.:				Email:
SECTON III. SERVICE INFORMATION
Period of Performance: From(mm/dd/yy): To(mm/dd/yy):
Description of Services Provided: Checkpoint Coverage
Total No. of LEO Hours Billed:				Hourly Rate: Rate per Agreement or Actual (whichever is less).				Total Reimbursement Request:			$-
Actual Hourly Rate:					Actual Cost of LEO Coverage for Performance Period Submitted:
SECTON IV. BANKING INFORMATION
Routing Transit No.:								Type of Account:
Depositor Account No.:
Please update all banking information through the System for Award Management/SAM (https://www.sam.gov/portal/public/SAM/). If you experience any issues you may contact the U.S. Coast Guard Finance Center/FINCEN at 866/606-8220 or 757/523-6920 for assistance with the SAMS system and for pament inquiries. Payment status may also be obtained online at https://www.fincen.uscg.mil/secure/HS_PayHist/PH_menu_TSA.htm Our office does not distribute the reimbursable payments directly.
SECTON V. CERTIFICATIONS
I certify that the information provided is true and accurate based on the actual hours performed at the TSA Security Checkpoint(s) and at the hourly rate(s) billed. All information provided is for on-site law enforcement coverage provided to the above mentioned airport in accordance the terms and conditions of the LEO Agreement. I understand that audits may be performed on an unscheduled basis within any given performance period.
REQUESTOR'S AUTHORIZED REPRESENTATIVE
Name:								Contact No.:
(Printed)
Signature:								Date:
SECTON VI. CHECKPOINT LOG - WORKSHEET
AIRPORT CODE:
DATE		ACTIVITY (Checkpoint Coverage, Perimeter, etc.)		TOTAL HOURS		BASE HOURLY RATE		FRINGE RATE		TOTAL
1										$-
2										$-
3										$-
4										$-
5										$-
6										$-
7										$-
8										$-
9										$-
10										$-
11										$-
12										$-
13										$-
14										$-
15										$-
16										$-
17										$-
18										$-
19										$-
20										$-
21										$-
22										$-
23										$-
24										$-
25										$-
26										$-
27										$-
28										$-
29										$-
30										$-
31										$-
				0:00		$-		$-		$-
Please indicate which benefits are included in your average fringe rate. Please also give the percentage or dollar amount for each benefit used.
Fringe Benefits Included:					Yes				No
Social Security
Retirement
Disability Insurance
Workers Compensation
Healthcare Insurance
Pension
Life Insurance
Fringe Benefits are an added _____% on top of the base salary.
SECTON VII. - REIMBURSEMENT REQUEST
PROGRAM FUNCTION/ACTIVITIES								Amount
Programs Outlays to Date
Federal Share Amount
Non-Federal Share Amount
Federal Payments Received To Date
Federal Share Now Requesting