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 
MILEAGEt 
AMOUNT 
‘Railroad, steamship, airplane, bus, etc. 
fAbbreviate'class of service or accommodations used. Railroad: F, first class; I, intermediate class; M, mixed class; 0, 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. 
U. a. QOVERNMBKT fBINTIKG OmCB 10-1664a 
1 
i U 
Bsgci Z* 
• • • -..vyr 
■V 
standard Form No. 1012a—Revised 
Fokm Approved bt 
Comptroller General, U. S. 
July 19, 1937 
General Regulations No. 88 
VOUCHER FOR PER MEA AND/OR REIMBURSEMENT d o Vou No 
OF EXPENSES INCIDENT TO OFFICIAL TRAVEL Bureau No. ___ 
(Statement of account must be completely ^e^ prior^|^^^tu^^d there d^^tion unless initialed or signed by him) 
(Department, burelSj^ 
Official Headquarters_ 
General Accounting Office 
PREAUDIT 
Certified for payment in the 
sum of $„__ 
Comptroller General of 
THE United States 
By- 
PAID BY 
Domicile___ Residence 
(For use of Postal Service only) 
(For use of Paying OfTice) 
FOR 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 from_-_, 19_, 
to_, 19_, as per itemized statement within, under authority No. —__, dated_, 
19_, copy of which is attached,* or has been previously furnished with voucher No._, paid_, 
19-, by - S 
(Name of disbursing officer) 
(Payee will NOT use this space) 
Differences_ 
Account verified correct for.. 
AMOUNT 
Dollars Cents 
(Signature or initials). 
MEMORANDUM 
ACCOUNTING CLASSIFICATION (For completion by administrative oflioe) 
Approprution, Limitation 
OR Project Symbol 
Approprution Title 
Limitation or Project 
Approprution 
Amount 
Amount 
$ 
9 f . .... 
Cost Account 
Object of Expenditure 
Allotment Symbol 
Amount 
Encumbrance 
Liquidated 
Symbol 
Amount 
$ _ 
Symbol 
Amount 
$-—. 
Paid by 
f Check No. 
I Cash, $ . 
, dated 
on 
19 
19_, for $. 
SIGN 
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—leeia 
