Form xxxx HP Travel Reimbursement Form

U.S. Department of Justice
REIMBURSEMENT FORM
PLEASE RETURN THIS FORM WITHIN 2 WEEKS OF THE INTERVIEW

Name:

Social Security Number:

Mailing Address (street, city, state, zip code):
Telephone & Fax: (include area codes)

EXPENDITURES
Do not include any food purchases; you will get partial M&IE if your travel exceeded 12 hours. See the Travel
Memo at www.usdoj.gov/oarm under the "Honors Program/Interview" link for details. Please attach receipts
for expenses over $75.00.
Date

Taxi Cabs
(Only if preauthorized or
specifically approved
due to late flight, etc)

Parking/Fare/Toll

Other

Mileage

(Include metrorail,
train, etc. Do not

(Please specify,
e.g., lodging if
overnight stay was
authorized. If
lodging taxes

(If travel by private
auto was authorized)

include prepaid air

fare.)

apply, list

separately.

Total

See www.gsa.govfor
mileage rates in effect at
the time of
travel
Mileage
Rate

# of
Miles
Mileage
Rate

# of
Miles
Mileage
Rate

# of
Miles

$

GRAND TOTAL

I certify that this claim is true and correct to the best of my knowledge and belief and that payment or
credit has not been received by me.
Signature:

Date:

Please fax back to the attention of your scheduler at 202-307-0862
PRIVACY ACT STATEMENT (This information is provided pursuant to the Privacy Act of 1974, 5 U.S.C.§552a[e][3]): This form requests
personal information that is relevant and necessary for reimbursing expenses incurred during your travel to Washington, DC, for your interview(s)
with components participating in the Attorney General's Honors Program. OARM collects this information in order to reimburse authorized
expenses incurred during travel to and from your interview(s). OARM has the authority to ask for this information pursuant to 5 U.S.C. §301, and
28 C.F.R. Part 0.15(b)(2). Because accepting reimbursement for travel expenses is voluntary, you are not required to provide any personal
information. However, failure to provide this information could result in your not receiving reimbursement for your travel expenses.