5210/12 Firm Travel Voucher

OMB Number: 3064-0122
Expiration Date: 01/31/2023

Federal Deposit Insurance Corporation

FIRM TRAVEL VOUCHER
PRIVACY ACT STATEMENT
The FDIC is authorized to request this information from you by 12 U.S.C § 1819, and Executive Order 9397 as amended. The
information collected will be primarily used to process your request for travel expense reimbursement. Furnishing the requested
information is voluntary, but failure to provide the requested information in whole or in part may delay or prohibit any further
consideration of your request for travel expense reimbursement. The information you provide may be provided to appropriate Federal,
state, local or foreign agencies and law enforcement authorities; to a court, administrative tribunal, or a party in litigation; and to
contractors, agents and other third parties as authorized by law and in accordance with any of the other routine uses described in the
FDIC Financial Information Management Records (FDIC 30-64-0012) System of Records available at www.fdic.gov/about/privacy/. If
you have questions or concerns about the collection or use of the information, you may contact the FDIC's Chief Privacy Officer at
Privacy@fdic.gov.

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.

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FDIC 5210/12 (5-21)

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OMB Number: 3064-0122
Expiration Date: 01/31/2023

Federal Deposit Insurance Corporation

FIRM TRAVEL VOUCHER
INSTRUCTIONS: Please provide all information requested.
SECTION I - TRAVELER'S INFORMATION
1. Name

2. Telephone

3. Federal Tax ID

4. Invoice Number

5. Address (Street, City, State, ZIP Code)

6. Firm Name

7. Matter Number

SECTION II - EXPENSES
8. Complete the following.
Amounts Claimed
Date

Nature of Expense
(Departure/Arrival Times are Per Diem Payment)

Mileage

Per Diem

Lodging

Air Fare

Car Rental

Other

Subtotals:
Total Reimbursement:
SECTION III - TRAVELER'S CERTIFICATION
I certify the amounts claimed in Section II - Expenses is correct.
9. Signature

10. Date

SECTION IV - FDIC OVERSIGHT ATTORNEY 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.
11. Name

13. Signature

FDIC 5210/12 (5-21)

12. Title

14. Date

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