STATEMENT OF TRAVEL PERFORMED FOR WHICH REIMBURSEMENT IS NOT CLAIMED 
BY TRAVELER 
*Railroad, steamship, airplane, bus, etc. * 
fAbbreviate class of service or accommodations used. Railroad: R, first class; I, intermediate class; M, mixed class; C, coach; P, Pullman accommodations; DR, drawing room; 
CP, 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. 
s. As many copies of the approved memorandum voucher may be made as required for administrative purposes. 
& u. s. oiivEByausT raiNTma ophcb 10—1664a 
StaS^ard Form No. 1012a—Revised 
Fokm Appkoved by 
Comptroller General, U. S. 
July 19, 1937 
General Regulations No. 88 
VOUCHER FOR PER DIEM AND/OR REIMBURSEMENT p o Vou m 
OF EXPENSES INCIDENT TO OFFICIAL TRAVEL Bureau 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) 
THE UNITED STATES, Dr., 
SBiitbsonlaa !}*0. 
Oflficial Headquarters__ 
General Accoiinling Office 
PREAUDIT 
Certified for payment in the 
sum of$.,... 
Comptroller General of 
the United States 
By. 
Domicile_ Residence 
' (Fnr use of Postal Service only) 
PAID BY 
(For use of Paying Office) 
of 
FOR PER DIEM in lieu of subsistence, mileage for personally owned motor §0^|ir“d4/r REIMBURSEM^T 
l^wel aij^ other exposes paid by me in the discharge of official duty from_ _ 
to _, if?...., as per itemized statement within, under authority No.__, dated__?T. 
19^..., copy of which is attached,* or has been previously furnished with voucher No._, paid_ 
.-rf 
19. 
by 
(Name of disbursing officer) 
•Vi 
(K 
(Payee will NOT use this space) 
Differences___ 
Account verified correct for. 
(Signature or initials)— 
AMOUNT 
Dollars 
89 
Cents 
.r? 
A.-'t—VU .V.. . .. 
MEMORANDUM 
880»89 
Appkopbution, Limitation 
OR Project Symbol 
a8-inioo4.oo4 
Allotment Symbol 
~01 " 
0880 
Paid by 
Check No. 
Cash, $. 
ACCOUNTING CLASSIFICATION (For completion by administrative office) 
Appropriation Title 
CoopercitioB wttb Jmeriesii 
Limitation or Project 
Amount 
^806;89 
$ - 
Amount 
1»6ioa 
Bncumbrance 
Liquidated 
I 90759 
886.00 
Cost Account 
Symbol 
08 
0850 
-I- 
Amount 
J0.89 
liswoo 
Appropriation 
$. - 
Amount 
Object of Expenditpre 
Symbol 
08 
0880 
Amount 
.90.59 
880.00 
, 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—1664» 
