FS-6500-229 Request for Reimbursement Form

USDA Forest Service Employees and Volunteers: FS-6500-229 (06/2007)

Volunteers: OMB 0596-0080 (Exp. 08/2010)

REQUEST FOR REIMBURSEMENT FORM (FSH 6509.11K, Chapter 50)

1. ORGANIZATION (Region/Station/Area and Unit)

     

2. CLAIMANT

a. NAME (Last, first, middle initial)

b. SOCIAL SECURITY NUMBER

     

     

c. MAILING ADDRESS

d. TELEPHONE NUMBER

     

     

Your Social Security Number is requested under the provisions of 31 U.S.C. 3325, for the purpose of disbursing Federal Money. Disclosure of this information is voluntary; failure to furnish information may delay payment. Collection and use is covered under Privacy Act System of Records USDA/OP-1 and is consistent with the provisions of 5 USC 552a (Privacy Act of 1974).

3. EXPENSES TO BE REIMBURSED

Show appropriate code in column (b):

MILEAGE RATE

AMOUNT CLAIMED

C O D E

MILEAGE

FARE OR TOLL

INCIDENTAL AND OTHER EXPENSES

Volunteers: A – Local travel B – Incidental Expenses specified in Volunteer Agreement C – Other Expenses (Itemized)

Employees: D – Health & Wellness Plan Expenses E – Professional License/Certification Fee F – Professional Liability Insurance G – Other Expenses (Itemized)

     ¢

DATE

NO. OF MILES

(Explain expenditures in specific detail)

(a)

(b)

(c)

(d)

(e)

(f)

     

   

     

     

     

     

     

     

     

   

     

     

     

     

     

     

     

   

     

     

     

     

     

     

     

   

     

     

     

     

     

     

     

   

     

     

     

     

     

     

     

   

     

     

     

     

     

     

     

   

     

     

     

     

     

     

     

   

     

     

     

     

     

     

If additional space is required, continue on next page

SUBTOTALS CARRIED FORWARD FROM OTHER PAGES

     

     

     

     

4. AMOUNT CLAIMED (Total of cols d ,e, ,f)



$      

TOTALS

     

     

     

     

6. I recommend reimbursement of expenses:

5. I certify that this claim is true and correct to the best of my knowledge and belief and that I have not received reimbursement for these expenses.

SUPERVISOR OR OTHER APPROVING OFFICIAL SIGN HERE



DATE

CLAIMANT SIGN HERE



DATE

     

     

PRINT NAME HERE



8. REFERENCE NUMBERS:

TITLE



Volunteers enter Agreement Number:      

Employees/Volunteers enter Requisition/Obligation Number:      

7. ACCOUNTING CLASSIFICATION

9. Remarks:

Budget Organization Code (RRUU):

    

     

     

Job Code:

    

     

3. EXPENSES TO BE REIMBURSED - CONTINUED
			Show appropriate code in column (b):			MILEAGE RATE	AMOUNT CLAIMED
		C O D E					MILEAGE	FARE OR TOLL	INCIDENTAL AND OTHER EXPENSES
			Volunteers: A – Local travel B – Incidental Expenses specified in Volunteer Agreement C – Other Expenses (Itemized)	Employees: D – Health & Wellness Plan Expenses E – Professional License/Certification Fee F – Professional Liability Insurance G – Other Expenses (Itemized)		     ¢
DATE						NO. OF MILES
			(Explain expenditures in specific detail)
(a)		(b)				(c)	(d)	(e)	(f)
     	   		     			     	     	     	     
     
     	   		     			     	     	     	     
     
     	   		     			     	     	     	     
     
     	   		     			     	     	     	     
     
     	   		     			     	     	     	     
     
     	   		     			     	     	     	     
     
     	   		     			     	     	     	     
     
     		   	     			     	     	     	     
     
     		   	     			     	     	     	     
     
     		   	     			     	     	     	     
     
     		   	     			     	     	     	     
     
     		   	     			     	     	     	     
     
     		   	     			     	     	     	     
     
     		   	     			     	     	     	     
     
     		   	     			     	     	     	     
     
     		   	     			     	     	     	     
     
     		   	     			     	     	     	     
     
     		   	     			     	     	     	     
     
Total each column and enter on the front, subtotal line						     	     	     	     

Burden Statement for Volunteers

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0596-0080. The time required to complete this information collection is estimated to average 15 minutes/hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, gender, religion, age, disability, political beliefs, sexual orientation, and marital or family status. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA’s TARGET Center at 202-720-2600 (voice and TDD).

To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, DC 20250-9410 or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.

Instructions

Employees and volunteers are to use this form to request reimbursement of incidental expenses. Submit completed form, with original signatures and supporting documentation to the Albuquerque Service Center (B&F), Miscellaneous Payments 101B Sun NE, Albuquerque, New Mexico 87109.

Directions for Employees

Block 1 - Enter name of Forest Service organization.

Block 2 - Claimant Information- Self-explanatory.

Block 3 – Expenses to be reimbursed

1. Date expenses incurred

2. Enter code for type of expenses

3. For local travel using personal vehicle, enter point of departure and destination, otherwise enter explanation for expense

4. For local travel using personal vehicle, enter point of departure and destination, otherwise enter explanation for expense

5. Calculate miles driven.

6. Calculation of miles driven times mileage rate

7. Fares or tolls charges for local travel

8. Amount of reimbursement claimed excluding mileage, tolls, or fares

Block 4 - Amount Claimed –Enter totals of columns d, e, and f.

Block 5 - Claimant sign.

Note: If the employee is requesting reimbursement for supplies, the FS-6500-229 form must be signed by a warranted procurement official

Block 6 - Employee Supervisor sign, print name and title

Block 7 - Accounting Classification enter valid budget organization code (sometime referred to as “override”) and Job Code. Must obtain this information from supervisor

Block 8 - Reference numbers: Enter the requisition number or obligation number, if available

Block 9 – Remarks. Enter additional information that may be helpful to process your claim.

Directions for Volunteers

For new volunteer, submit Vendor Code Information Worksheet (FS-6500-231) with first reimbursement request. Submit a Vendor Code information Worksheet for volunteer address change or banking information for EFT payment.

Block 1 - Enter name of Forest Service organization.

Block 2 - Claimant Information- Self-explanatory.

Block 3 – Expenses to be reimbursed

1. Date expenses incurred

2. Enter code for type of expenses

3. For local travel using personal vehicle, enter point of departure and destination, otherwise enter explanation for expense

4. For local travel using personal vehicle, enter point of departure and destination, otherwise enter explanation for expense

5. Calculate miles driven.

6. Calculation of miles driven times mileage rate

7. Fares or tolls charges for local travel

8. Amount of reimbursement claimed excluding mileage, tolls, or fares

Block 4 - Amount Claimed –Enter totals of columns d, e, and f.

Block 5 - Claimant sign.

Note: Reimbursement request must match the terms of the Volunteer Agreement. Agreement must be signed by Line Officer or Delegated Official.

Block 6 – Volunteer Supervisor sign, print name and title

Block 7 - Accounting Classification enter valid budget organization code (sometime referred to as “override”) and Job Code. This information will be obtained from the supervisor

Block 8 - Reference numbers. Enter the Volunteer agreement number and requisition number or obligation number, if available

Block 9 – Remarks. Enter additional information that may be helpful to process your claim.