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
_______________ ___________ _________________________
_______________ ___________ _________________________
_______________ ___________ _________________________
_______________ ___________ _________________________
_______________
___________ _________________________