f 
standard Form No. 1012a — Revised 
Form Approved by 
Comptroller General, U. S. 
^ July 19, 1937 
VOUCHER FOR PER WEM AND/OR REIMBDRSEMENI n n v„„ „„ 
“ OF EXPENSES INCIDENT TO OFFICIAl TRAVEL no 
(Statement of account must be completely filled in by payee prior to signature, and there must not be any erasure or alteration unless initialed or signed by him) 
General Accounting Office 
U. s. Stei^»<ailaa Ihstitatioa, 0. s. HaUoaal Mumub. 
PAID BY 
PREAUDIT 
Certified for payment in the 
•^iTm nf iR 
' (Department, bureau, or establishmem) 
THE UNITEO STATES. Dr., To Walao L. SQlSBltt 
(Payee) 
U. S. Natioaal MaBaira, Wai^loi^toa, D.C. 
125-100 
Comptroller General of 
THE United States 
(Address) 
Official Headquarters 
By 
Domicile Residence .. 
(For use of Postal Service only) 
(For use of Paying Office) 
FOE PER DIEM in lieu of subsistence, mileage for personally owned motor vehicle, and/or REIMBURSEMENT 
of travel and other expenses paid by me in the discharge of official duty fro m 89 ^ 19.^ 
to , as per itemized statement v/ithin, under authority No.^ , dated 
6 
copy of which is attached,* or has been previously furnished with voucher No , paid 
(Name of disbursing officer) 
19 
■. by 
$ 
(Payee will NOT use this space) 
Differences 
Account verified correct for. $ 
(Signature or initials). 
AMOUNT 
Dollars 
17 A 
Cents 
84 
MEMORANDUM 
i 
174 #84 
ACCOUNTING CLASSIFICATION (For completion by administrative office) 
Approprlation, Limitation 
OR Project Symbol 
33-19X1004.00X 
Appropriation Title 
(Jo^erattoa the 
Ifepamie e tr^assfe^ 
iiai i94t 
Limitation or Project 
Amount 
$' 
174.84 
Appropriation 
Amount 
$ 
174.84 
Allotment Symbol 
Amount 
06S0 
0570 
^- 67 vE 9 
Encumbrance 
Liquidated 
■|IC 57;55 
Cost Account 
Symbol 
11580 
Amount 
55 ^ 
Object of Expenditure 
Symbol 
0580 
Amount 
67 . 88 ^ 
f Check No. , dated , 19.. , for $ 
Paid by ( SIGN 
I Cash, $ , on . , 19 ORIGINAL 
, - - — ONLY 
i 
on Treasurer of the United States 
in favor of payee named above. 
(Signature of payee) 
*If there was no prior authority state circumstances which rendered securing prior authority impracticable. 
10— 1664a 
\ 
