NRC Form 64 Travel Voucher

NRC FORM 64

U.S. NUCLEAR REGULATORY COMMISSION

(MM-YYYY)

TRAVEL VOUCHER
Schedule of Expenses
and Amount Claimed

EXPIRES: (MM/DD/YYYY)

APPROVED BY OMB: NO. 3150-0192

Estimated burden per response to comply with this voluntary collection request 1 hour for NRC Form 64. NRC
uses the information to authorize payment for official travel. Send comments regarding burden estimate to the
FOIA, Library, and Information Collections Branch (T-6 A10M), U. S. Nuclear Regulatory Commission,
Washington, DC 20555-0001, or by e-mail to [email protected], and the OMB reviewer at: OMB
Office of Information and Regulatory Affairs, (3150-0192), Attn: Desk Officer for the Nuclear Regulatory
Commission, 725 17th Street NW, Washington, DC 20503; e-mail: [email protected]. The NRC
may not conduct or sponsor, and a person is not required to respond to, a collection of information unless the
document requesting or requiring the collection displays a currently valid OMB control number.

1. Name (Last, First, Middle Initial)

2. Office Telephone Number (Include Area Code) (Enter 10 numeric digits)

3. Mailing Address

4. Is this a new address since you last traveled?

Yes
6. Travel Begin Date (MM/DD/YYYY)

5. Do you have Direct Deposit?

Yes

No
7. Travel End Date (MM/DD/YYYY)

No
8. Expenses Claimed
(From page 2 - Schedule of expenses and amount claimed)

Expenses

Amount Claimed
Other Expenses

A. Subsistence and
other expenses (Grand Total from Page 2)
B. Plane, Train, Bus
(Paid by Traveler) (If applicable)

C. TOTAL CLAIM

9. I CERTIFY THAT THIS VOUCHER IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE
AND BELIEF AND THAT PAYMENT OR CREDIT HAS NOT BEEN RECEIVED BY ME.
Typed Name of Traveler (Last, First, Middle Initial)

Signature of Traveler

10. THIS VOUCHER IS APPROVED.
Typed Name of Approving Official

Signature of Approving Official

NRC FORM 64 (MM-YYYY)

Page 1 of 3

U.S. NUCLEAR REGULATORY COMMISSION

NRC FORM 64
(MM-YYYY)

TRAVEL VOUCHER (Continued)

SCHEDULE OF EXPENSES AND AMOUNT CLAIMED
Name (Last, First, Middle Initial)

Date

Date (MM/DD/YYYY)

Nature of Expense

Authorized
Mileage (e.g., .50)

¢

Number of Miles

Amount Claimed

GRAND TOTAL - THIS PAGE
(Amount to be included in Item 8.C, Page 1)
NRC FORM 64 (MM-YYYY)

Page 2 of 3

PRIVACY ACT STATEMENT

NRC Form 64 Travel Voucher,
Schedule of Expenses and Amount Claimed

Pursuant to 5 U.S.C. 552a(e)(3), enacted into law by Section 3 of the Privacy Act of 1974 (Public Law 93-579), the
following statement is furnished to individuals who supply information to the U.S. Nuclear Regulatory Commission
(NRC) on NRC Form 64. This information is maintained in a system of records designated as GSA/GOVT4 Contracted Travel Services Program and described at 74 Federal Register 26700 (June 3, 2009).
1. AUTHORITY: 31 U.S.C. 3511, 3512, and 3523; 5 U.S.C. Chapter 57; and implementing Federal Travel
Regulations (41 CFR Chapters 300-304).
2. PRINCIPAL PURPOSE(S): To make reimbursement claims for approved and authorized travel expenses, per
diem, and other change of station expenses
3. ROUTINE USE(S): In addition to the other types of disclosures permitted under subsection of the Privacy Act,
information from this system of records may be disclosed:
(a.) to another Federal agency, Travel Management Center (TMC), online booking suppliers, and airlines; to
Federal, State, local or foreign agencies when relevant to a potential or actual civil or criminal violation;
(b.) To a Federal, State, local, or foreign agency responsible for investigating, prosecuting, enforcing, or carrying
out a statute, rule, regulation, or order, where agencies become aware of a violation or potential violation of civil or
criminal law or regulation.
(c.) To another Federal agency or a court when the Federal Government is party to a judicial proceeding.
(d.) To a Member of Congress or staff on behalf and at the requests of the individual who is the subject of the
record.
(e.) To a Federal agency employee, expert, consultant, or contractor in performing a Federal duty for purposes of
authorizing, arranging, and/or claiming reimbursement for official travel, including, but not limited to, traveler
profile information.
(f.) To a credit card company for billing purposes, including collection of past due amounts.
(g.) To an expert, consultant, or contractor in the performance of a Federal duty to which the information is
relevant.
(h.) To a Federal agency by the contractor in the form of itemized statements or invoices, and reports of all
transactions, including refunds and adjustments to enable audits of charges to the Federal Government.
(i.) To a Federal agency in connection with the hiring or retention of an employee; the issuance of a security
clearance; the reporting of an investigation; the letting of a contract; or the issuance of a grant, license, or other
benefit to the extent that the information is relevant and necessary to a decision.
(j.) To an authorized appeal or grievance examiner, formal complaints examiner, equal employment opportunity
investigator, arbitrator, or other duly authorized official engaged in investigation or settlement of a grievance,
complaint, or appeal filed by an employee to whom the information pertains.
(k.) To the Office of Personnel Management (OPM), the Office of Management and Budget (OMB), or the
Government Accountability Office (GAO) when the information is required for program evaluation purposes.
(l.) To officials of labor organizations recognized under 5 U.S.C. chapter 71 when relevant and necessary to their
duties of exclusive representation concerning personnel policies, practices, and matters affecting working
conditions.

(m.) To a travel services provider for billing and refund purposes.
(n.) To a carrier or an insurer for settlement of an employee claim for loss of or damage to personal property
incident to service under 31 U.S.C. 3721, or to a party involved in a tort claim against the Federal Government
resulting from an accident involving a traveler.
(o.) To a credit reporting agency or credit bureau, as allowed and authorized by law, for the purpose of adding to a
credit history file when it has been determined that an individual's account with a creditor with input to the system
is delinquent.
(p.) Summary or statistical data from the system with no reference to an identifiable individual may be released
publicly.
(q.) To the National Archives and Records Administration (NARA) for records management purposes.
(r.) To appropriate agencies, entities, and persons when (1) The Agency suspects or has confirmed that the
security or confidentiality of information in the system of records has been compromised; (2) the Agency has
determined that as a result of the suspected or confirmed compromise there is a risk of harm to economic or
property interests, identity theft or fraud, or harm to the security or integrity of this system or other systems or
programs (whether maintained by GSA or another agency or entity) that rely upon the compromised information;
and (3) the disclosure made to such agencies, entities, and persons is reasonably necessary to assist in
connection with GSA's efforts to respond to the suspected or confirmed compromise and prevent, minimize, or
remedy such harm. For additional detail on these routines uses, please see the GSA/GOVT-4 system notice.
4. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT ON INDIVIDUAL OF NOT PROVIDING
INFORMATION: Disclosure is voluntary. However, if the requested information is not provided, reimbursement may be
denied.
5. NRC CONTACT AND ADDRESS INFORMATION: Chief, Travel Operations Branch, Division of the Controller, Office of
the Chief Financial Officer, U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001.