To:             Component Head

From:         Employee

Through:     Designated Ethics Official

Subject:      Approval of Travel Reimbursement
 

I am requesting your approval for acceptance by the Justice Department of payment of expenses for travel to attend a meeting or similar function related to my official duties. The following information is supplied in support of my request:
 

        1.     The sponsor of the event: _____________________________________

        2.     The location of the event: ______________________________________

        3.     The date(s) of the event:  ______________________________________

        4.     The nature of the event: _______________________________________

        5.     My position: ________________________________________________

        6.     The travel dates: _____________________________________________

        7.     The name of any organization other than the sponsor offering to pay expenses: __________

        8.     Description and estimated cost of benefits to be provided (i.e., airfare, lodging, meals,
                conference fee):

                 _____________________________________________________________________
                 _____________________________________________________________________

        9.     Type of benefits to be paid in kind: ___________________________________________

      10.     Type of benefits to be paid by a check made out to the Justice Department:   ____________
                 ___________________________________
 

      11.     I am ____ am not ____ working on any matter pending before the Department that would
                affect the interests of the organization paying my expenses.

After conducting a conflict of interest analysis, I recommend that the request to accept travel expenses be approved.
 

DATE: ___________                   __________________
                                                     Ethics Official
 

APPROVED ______________
 

DISAPPROVED ___________
 

DATE: ___________________    __________________
                                                      Component Head
 
 

AFTER RECEIVING PAYMENT FOR YOUR TRAVEL EXPENSES, PLEASE PROVIDE THE FOLLOWING INFORMATION AND RETURN A COPY OF THE ENTIRE FORM TO YOUR ETHICS OFFICIAL. (YOU SHOULD NOW REPORT EXACT AMOUNTS ALTHOUGH YOU MAY PROVIDE THE APPROXIMATE COST OF MEALS IF THE EXACT COST IS NOT EASILY AVAILABLE.)
 
 
 

TYPE OF BENEFIT                COST                    ACCEPTED IN KIND OR
      RECEIVED                                                      BY CHECK PAYABLE TO DOJ

_______________                   ___________        _________________________

_______________                   ___________        _________________________

_______________                   ___________        _________________________

_______________                   ___________        _________________________

_______________                   ___________        _________________________