Form 5210/12 Firm Travel Voucher

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OMB Number: 3064-0122
EXPIRATION DATE: 12/31/2019

Federal Deposit Insurance Corporation

FIRM TRAVEL VOUCHER
SECTION I – TRAVELER INFORMATION
1. NAME OF TRAVELER (Last, First, MI)

2. HOME OFFICE

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

6. FIRM NAME

8. DATE

16.

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

3. FEDERAL TAX ID NUMBER

4. INVOICE NUMBER

7. MATTER NUMBER

10. Mileage

11. Per
Diem

AMOUNTS CLAIMED
13. Air
Fare
12. Lodging

14. Car
Rental

15. Other

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, as amended. 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)