Reimbursement Request

OMB Number: 11050030 Expiration date: 07/31/2019

U.S. Department of Justice

Honors Program Reimbursement Form

PLEASE RETURN THIS FORM WITHIN 2 WEEKS OF THE INTERVIEW
Email to [email protected] using the Subject line: Your Last Name; First Name – HP Reimbursement
Name: ______________________________________________

Social Security Number: ___________________

Mailing Address: ______________________________________
______________________________________
______________________________________

E-Mail: _________________________________
Telephone: ______________________________
FAX: ___________________________________

Traveled From: _______________ To: ________________ Round Trip? Yes
Cities From: _______________ To: ________________ Round Trip? Yes
From: _______________ To: ________________ Round Trip? Yes

No Travel Dates: _______ to _______
No Travel Dates: _______ to _______
No Travel Dates: _______ to _______

Payment will be issued by electronic fund transfer. Please provide the following information on your checking or savings
account:
•

ABA Routing Number (On a checking account, this is a nine-digit number on the bottom, left side of a check. Ask
your bank if you have questions). __________________

•

Your bank account number: ________________________

Checking or

Savings

EXPENSES CLAIMED (Receipts are required for expenses over $75.00.) Scan and attach to email with
reimbursement form) Do not claim food purchases; you will receive M&IE if your travel exceeded 12 hours.
See Honors Program Interviews & Travel for details.
TYPE

DATE(S)

AMOUNT

Lodging (receipt required)
Lodging Tax
Taxi/Other Ground Travel Services
List each fare seperately.

Mileage (If travel by private auto was authorized) Reimbursement is limited to the mileage
rate at the time of travel. See www.gsa.gov for details.

Total miles:

Parking/Fare/Toll (Include Metrorail, train, etc. Do not include prepaid air/rail fare.)
Miscellaneous: Itemize below. Airline baggage charges will not be reimbursed.

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: ___________________

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 for your interview(s) with
components participating in the Attorney General's Honors Program. DOJ collects this information in order to reimburse authorized
expenses. 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). This information
can be shared in accordance with routine uses as published in system of record notice OPM/GOVT-1, General Personnel Records, 71 FR
35342, as modified by 77 FR 73694. 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 being reimbursed for authorized travel
expenses you incur in the interview process.

DOJ USE ONLY:
APPROVED ___________________________________ DATE _________________