NPS 10 67 Claim for Reimbursement for Volunteer Expenses

Form No. 10-67 OMB 0596-0080 (Exp. XX/20XX)

Rev. (6/2007)

UNITED STATES DEPARTMENT OF THE INTERIOR

NATIONAL PARK SERVICE

VOLUNTEERS-IN-PARKS PROGRAM

_______________________________________

AREA

_______________________________________

VOUCHER NO.

_______________________________________

SCHEDULE NO.

Claim for Reimbursement for Volunteer Expenses

     

NAME OF CLAIMANT - Last, first, middle initial (please print)

     

ADDRESS (Street, city, state, zip code)

Date Expenses Incurred Mo./Day/Yr.	Amount Claimed for (last, first, m.i.)
	Local Transportation	Number Of Miles	Meals	Lodging	Uniforms/ Costumes	Other Expenses
     	     	     	     	     	     	     
     	     	     	     	     	     	     
     	     	     	     	     	     	     
     	     	     	     	     	     	     
     	     	     	     	     	     	     
     	     	     	     	     	     	     
     	     	     	     	     	     	     
     	     	     	     	     	     	     
     	     	     	     	     	     	     
     	     	     	     	     	     	     
     	     	     	     	     	     	     
     	     	     	     	     	     	     
     	     	     	     	     	     	     
     	     	     	     	     	     	     
     	     	     	     	     	     	     
     	     	     	     	     	     	     
Subtotal:	     	     	     	     	     	     
GRAND TOTAL $      

I certify that this claim is correct and proper and that payment or credit has not been received
Signature of Volunteer making claim			Date
Approved, as advantageous to the government, for $     
VIP Coordinator or Designee			Date
Accounting Classification Organization Code      	Pursuant to authority vested in me, I certify that this voucher is correct and proper for payment in the amount of $     
		Authorized Certifying and Paying Officer			Date
Paid by check no.      
Received in cash, $     		Signature of Volunteer			Date

PRIVACY ACT STATEMENT

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).

Burden Statement

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 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Department of the Interior, National Park Service Volunteers-In-Parks Program Coordinator, 1849 C Street NW, 2450, Washington, DC 20240.

The U.S. Department of the Interior (USDI) 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.) To file a complaint of discrimination or persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) contact Volunteers-In-Parks Program Coordinator, National Park Service, 1849 C Street NW, 2450, Washington, DC 20240. USDI is an equal opportunity provider and employer.

Group Reimbursement Information

This form to be used only with groups who are operating under a Form 10-86 (Agreement for Sponsored Voluntary Services) and whose members are requesting reimbursement. List the total group claim on this form (by categories), and form must be signed and submitted by group leader or liaison.

Name of Group Member	Amount Claimed	Date	Signature
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