STATEMENT OF TRAVEL PERFORMED FOR WHICH REIMBURSEMENT IS NOT CLAIMED 
BY TRAVELER 
DATE OP 
TRAVEL 
NO. OF TRANS¬ 
PORTATION 
REQUEST OR 
SPEEDOMETER 
READING 
FROM— 
TO— 
VIA 
(Kind of carrier 
or vehicle)* 
CLASS OR 
MILEAGEf 
AMOUNT 
‘Railroad, steamship, airplane, bus, etc. 
fAbbreviate class of service or accommodations used. Railroad: F, 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. Kie 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. 8. GOVERNMENT PRINTING OFFICE 10 1664a 
Page 2 
Standard Form No. 1012a —Revised 
Form Approved by 
COMPTROLLER GENERAL, U. S. 
W July 19, 1937 
General-Regulations No. 88 
VOUCHER FOR PER DIEM AND/OR REIMBURSEMENT D 0 Vtm No 
OF EXPENSES INCIDENT TO OFFICIAL IRAVE 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) 
General Accounting Office 
u. s. mithBOT&Qjk Iasil tuUoa „ 8* HaUQ&aX 
PAID BY 
PREAUDIT 
. (Department, bureau, or establishment) 
THE UNITED STATES, Dr., To ItX* A* Tlstsaore._ 
Certified for payment in the 
sum of $. 
(Payee) 
Bm national mtumm. fMs&ingtoa, 0*0. 
(Address) 
185-100 
COMPTROLLER GENERAL OF 
the United States 
Official Headquarters _ _C. 
By- 
Domicile_ Residence 
(For use of Paying Office) 
(For use of Postal Service only) 
d 
FOR PER DIEM in lieu of subsistence, mileage for personally owned motor vehicle, and/or REIMBURSEMENT 
of travel and other expenses paid by me in the discharge of official duty from_ISaJPCll 2 19.43k, 
to.... JPIjP, 1943c., as per itemized statement within, under authority No. dated?®6. 81__, 
.19.41, copy of which is attached,* or has been previously furnished with voucher No._, paid_, 
19-, by- 3 
(Name of disbursing officer) 
(Payee will NOT use this space) 
Differences_ 
Account verified correct for..._.$ 
(Signature or initials) 
AMOUNT 
Dollars 
Cents 
MEMORANDUM 
530.33 
ACCOUNTING CLASSIFICATION (For completion by administrative office) 
Appropriation, Limitation 
or Project Symbol 
Appropriation Title 
Limitation or Project 
Appropriation 
Amount 
Amount 
33-X9U0O4.004 
Cooperation eiifa the Amxlean 
s 55*0.35 
!^pubXio» p (transfer to 
^tbsoaiaa institution)» 1941 
Allotment Symbol 
Amount 
Encumbrance 
Liquidated 
Cost Account 
Object of Expenditure 
Symbol 
Amount 
Symbol 
Amount 
05 
s 6®0.85 
1520.35 
06 
,580.35 
06 
s 580.55 
Paid by 
Check No. 
, dated 
Cash, $. 
on 
, 19. 
1Q f , 380.33 J on Treasurer of the United States 
, 19-, for $--— | j n favor of payee named above. 
SIGN 
ORIGINAL 
(Signature of payee) 
*If there was no prior authority state circumstances which rendered securing prior authority impracticable. 
10—1664a 
