STATEMENT OF TRAVEL PERFORMED FOR WHICH REIMBURSEMENT IS NOT CLAIMED 
BY TRAVELER 
DATE OF 
TRAVEL 
NO. OF TRANS- 
PORTATION 
REQUEST OR 
SPEEDOMETER 
READING 
FROM— 
TO— 
VIA 
(Kind of carrier 
or vehicle)* 
CLASS OR 
MILEAQEt 
AMOUNT 
■ 
1 
1 
! 
1 
1 
1 
! 
1 
1 
i 
1 
4^ 
1 
i 
1 
i 
• 
i 
i 
( 
i 
• 
*Ilailroad, steamship, airplane, bus, etc. , _ „ ^ . 
tAbbreviate class of service or accommodations used. Railroad: F, first class; I, intermediate class; M, mixed class; C, coach; P, Pullman accommodations; DR, drawing room' 
OP, compartment; BR, bedroom; SOS, single occupancy section; SEC, section; LB, lower berth; UB, upper berth; S, seat. By other mode: Number of miles traveled. 
INSTRUCTIONS 
1. The provisions of the travel regulations must be strictly observed in order to avoid suspensions and disallowances in the accounts. 
2. When more space is required for itemization of the account, use continuation sheets (standard forms 1012b ^Revised and 
1012c — Revised) and fasten together in upper left-hand corner. 
3. As many copies of the approved memorandum voucher may be made as required for administrative purposes. 
V. a. QOVBRNUBNT rRIMTWO OFFIOB 
10— 16Q4a 
