REV FS-6500-229 Request for Reimbursement

USDA Forest Service FS-6500-229 (03/2008)

OMB 0596-0080 (Exp. 10/2010)

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

     

     

e. UNIT CONTACT NAME (Last, first, middle initial)

f. 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 are covered under Privacy Act System of Records OPM/GOVT-1 and USDA/OP-1, and are 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

(c) (Explain expenditures in specific detail)

(a)

(b)

(d)

(e)

(f)

(g)

     

   

     

     

     

     

     

     

     

   

     

     

     

     

     

     

     

   

     

     

     

     

     

     

     

   

     

     

     

     

     

     

If additional space is required, continue on next page

SUBTOTALS CARRIED FORWARD FROM OTHER PAGES

     

     

     

     

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

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$      

TOTALS

     

     

     

     

5. ACCOUNTING CLASSIFICATION

6. REFERENCE NUMBERS:

Budget Organization Code (RRUU):

    

Volunteers enter Agreement Number:      

Job Code:

    

Employees/Volunteers enter Requisition/Obligation Number:      

FRADULENT CLAIM: Falsification of an item in an expense account will result in forfeiture of the claim (28 USC 2514) and may result in a fine of not more than $10,000 or imprisonment for not more than 5 years or both (18 USC 287; ID 1001).

7. 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.

8. I recommend reimbursement of expenses:

CLAIMANT SIGN HERE



DATE      

SUPERVISOR OR OTHER DELEGATED OFFICIAL SIGN HERE



DATE      

9. Remarks:      

PRINT NAME HERE

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TITLE

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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
			(c) (Explain expenditures in specific detail)
(a)		(b)				(d)	(e)	(f)	(g)
     	   		     			     	     	     	     
     
     	   		     			     	     	     	     
     
     	   		     			     	     	     	     
     
     	   		     			     	     	     	     
     
     	   		     			     	     	     	     
     
     	   		     			     	     	     	     
     
     	   		     			     	     	     	     
     
     		   	     			     	     	     	     
     
     		   	     			     	     	     	     
     
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 for Employees

Employee use of FS-6500-229 is for incidental employee expenses not associated with travel. Procurement of project goods and services should be performed by a procurement official. If proper procurement procedure is not followed it will delay or prevent your reimbursement.

Fax completed form, with original signatures and supporting documentation (i.e. receipts, agreements, etc.) to the Albuquerque Service Center (B&F), Miscellaneous Payments 1-866-342-2321. The original package is to be filed as part of the unit’s official records.

Block 1 - Enter name of Forest Service organization.

Block 2 – Claimant Information; a. Name and b. Social Security Number is self-explanatory.

3. Office address where employee is assigned.

4. Telephone or cell number where you can be reached if there are questions.

5. Name of individual at the office who can provide detail information if needed, if you can not be reached (e.g. the support services specialist).

6. Unit contact Telephone or cell number.

Block 3 - Expenses to be reimbursed.

1. Date expenses incurred.

2. Enter code for type of expenses; (Only codes D, E, F or G apply to employees).

3. Describe the expense (e.g. Health & Wellness Expense; Bally Fitness Club membership fee, 85.00).

4. Leave Blank (travel expenses must be submitted on a travel voucher.)

5. Leave Blank (travel expenses must be submitted on a travel voucher.)

f. Leave Blank (travel expenses must be submitted on a travel voucher.)

g. Amount of reimbursement claimed.

Block 4 - Amount Claimed – Enter totals of column g.

Block 5 - Accounting Classification enter valid budget organization code (sometimes referred to as “override code” or Region/Unit (RRUU)) and Job Code. Obtain this information from your supervisor or other delegated official.

Block 6 - Reference numbers: Enter the requisition number or obligation number; if applicable (See local Budget Officer).

Block 7 - Claimant sign.

Block 8 – Employee’s Supervisor or other delegated official sign and date, print name and title.

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

Instructions 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.

Volunteers are to use this form to request reimbursement of incidental expenses. Submit completed form, with original signatures and supporting documentation (i.e. receipts, agreement, etc.) to the Albuquerque Service Center (B&F), Miscellaneous Payments 101B Sun NE, Albuquerque, New Mexico 87109. Retain a copy for your records

Block 1 - Enter name of Forest Service organization.

Block 2 - Claimant Information; a. Name and b. Social Security Number is self-explanatory.

3. Address that payment information should be sent. (Should match Vendor Code Information Worksheet.)

4. Telephone or cell number where you can be reached if there are questions.

5. Name of individual at the office who can provide detail information if needed, if you can not be reached (e.g. the support services specialist).

6. Unit contact telephone or cell number.

Block 3 - Expenses to be reimbursed.

1. Date expenses incurred.

2. Enter code for type of expenses; (Volunteers should used codes A, B, or C.)

3. Describe the expense (e.g. Travel to Forest with private owned vehicle; Toll charges 15.00).

4. Record miles driven to/from.

5. Calculation of miles driven times mileage rate (See Volunteers Agreement for mileage rate) if authorized.

6. Fare or toll charges for local travel if authorized.

7. Amount of subsistence or other authorized reimbursement claimed excluding mileage, tolls, or fares.

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

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

Block 5 - Enter valid budget organization code (sometime referred to as “override” or Regional/Unit (RRUU)) and Job Code. This information will be obtained from the supervisor.

Block 6 - Reference numbers. Enter the Volunteer agreement number and/or obligation number; if applicable (See local Budget Officer).

Block 7 - Claimant sign.

Block 8 – Volunteer’s Supervisor sign and date, print name and title.

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