WPC  77WPC Z>?{Aa ?Oy ?.m]@(?ND? O?O *?Oy?qOv?N?Og?Nr? O]?*hU=<~?N?8Og?M?Oek?O$?O 7>  (  (Untitled)'A,, , ,   UT ) 3    *    d +    d ,    d /0ijklmnopqrstuvwxyz{|}~P* * c:\inf42\forms\ad616r.wpf c:\inf41\forms\ad616r.wpfUS&&<<  >?f eh Terminal 1 ! d !  d      Terminal eb Arial " ! 2     d    Arial ev Times New Roman  ! 2 F  d    Times New Roman ex Helvetica-Narrow " ! &     d    Helvetica-Narrow eb Roman  ! 2    B    Roman eh Helve-WP " ! ?     d     Helve-WP ej Wingdings  ! } F  d     Wingdings eX  ! ? !  d     eh MS Serif  ! ? !  d     MS Serif ed Modern 2 ! 2    B    Modern ej Bodoni-WP  ! ? !  d     Bodoni-WP er MS Sans Serif " ! ? !  d    MS Sans Serif ed System " ! XS  d    System en Univers ATT " ! ? !  d     Univers ATT ep Times CG ATT  ! ? !  d     Times CG ATT ep Arial Narrow " ! &     d     Arial Narrow ez WP IconicSymbolsA  ! q !  d    WP IconicSymbolsA eh Umbra BT R ! &    d     Umbra BT e Times New Roman MT Extra Bold  ! ?    d    Times New Roman MT Extra Bold el Allegro BT R ! &    d     Allegro BT ?Ad A{?Oz jW c:\inf41\database\ AD616R.DBFHISTORY   i)TRVLAUTH     h TRVLAUTH i$SSN     h SSN i&LName     h LNAME i&FName     h FNAME i+MiddleName     h  MIDDLENAME i(AgyCode     h AGYCODE i)ORGOFCNO     h ORGOFCNO i+TrvlrOfcNo     h  TRVLROFCNO i*TravelFrm     h TRAVELFRM i)TravelTo     h TRAVELTO i*TYPECLAIM     h TYPECLAIM i%AMT8     h AMT8 i*REPT_DATE     h REPT_DATE i&LEAVE     h LEAVE i*DutyStatn     h DUTYSTATN i*ResdStatn     h RESDSTATN i)TotlLodg     h TOTLLODG i+NightApprv  K   h  NIGHTAPPRVK i*SpeclAddr      h SPECLADDR  i*ForgnAddr      h FORGNADDR  i(EFTAcct      h EFTACCT  i*trav_acct      h TRAV_ACCT  i*MailAddr1  #   h MAILADDR1# i*MailAddr2  #   h MAILADDR2# i)MailCity     h MAILCITY i*MailState     h MAILSTATE i(MailZip     h MAILZIP i(T_1[A1]     h T_1_A1_ i(T_1[B1]     h T_1_B1_ i(T_1[C1]     h T_1_C1_ i(T_1[D1]     h T_1_D1_ i(T_1[E1]     h T_1_E1_ i(T_1[F1] !    h T_1_F1_ i(T_1[A2] "    h T_1_A2_ i(T_1[B2] #    h T_1_B2_ i(T_1[C2] $    h T_1_C2_ i(T_1[D2] %    h T_1_D2_  i(T_1[E2] &    h T_1_E2_  i(T_1[F2] '    h T_1_F2_  i(T_1[A3] (    h T_1_A3_  i(T_1[B3] )    h T_1_B3_  i(T_1[C3] *    h T_1_C3_ i(T_1[D3] +    h T_1_D3_ i(T_1[E3] ,    h T_1_E3_ i(T_1[F3] -    h T_1_F3_ i(T_1[A4] .    h T_1_A4_ i(T_1[B4] /    h T_1_B4_ i(T_1[C4] 0    h T_1_C4_ i(T_1[D4] 1    h T_1_D4_ i(T_1[E4] 2    h T_1_E4_ i(T_1[F4] 3    h T_1_F4_ i(T_1[A5] 4    h T_1_A5_ i(T_1[B5] 5    h T_1_B5_ i(T_1[C5] 6    h T_1_C5_ i(T_1[D5] 7    h T_1_D5_ i(T_1[E5] 8    h T_1_E5_ i(T_1[F5] 9    h T_1_F5_ i(T_1[A6] :    h T_1_A6_ i(T_1[B6] ;    h T_1_B6_ i(T_1[C6] <    h T_1_C6_  i(T_1[D6]! =    h T_1_D6_! i(T_1[E6]" >    h T_1_E6_" i(T_1[F6]# ?    h T_1_F6_# i(T_1[A7]$ @    h T_1_A7_$ i(T_1[B7]% A    h T_1_B7_% i(T_1[C7]& B    h T_1_C7_& i(T_1[D7]' C    h T_1_D7_' i(T_1[E7]( D    h T_1_E7_( i(T_1[F7]) E    h T_1_F7_) i(T_2[A1] F    h T_2_A1_ i(T_2[B1] G    h T_2_B1_ i(T_2[C1] H    h T_2_C1_ i*XCSS_FARE  I    h XCSS_FARE  i%code J    h CODE i(T_5[C1] K    h T_5_C1_ i(T_5[C2] L    h T_5_C2_ i(T_5[C3] M    h T_5_C3_ i(T_5[C5] N    h T_5_C5_ i(T_5[C6] O    h T_5_C6_ i'out_us P    h OUT_US i(T_7[A1] Q    h T_7_A1_ i(T_7[B1] R    h T_7_B1_ i(T_7[C1] S    h T_7_C1_ i(T_7[D1] T    h T_7_D1_ i(T_3[A1] U    h T_3_A1_ i(T_3[D1] V    h T_3_D1_ i(T_3[E1] W    h T_3_E1_ i(T_3[F1] X    h T_3_F1_ i(T_3[A2] Y    h T_3_A2_ i(T_3[D2] Z    h T_3_D2_  i(T_3[E2] [    h T_3_E2_  i(T_3[F2] \    h T_3_F2_  i(T_3[A3] ]    h T_3_A3_  i(T_3[D3] ^    h T_3_D3_ i(T_3[E3] _    h T_3_E3_ i(T_3[F3] `    h T_3_F3_ i(T_3[A4] a    h T_3_A4_ i(T_3[D4] b    h T_3_D4_ i(T_3[E4] c    h T_3_E4_ i(T_3[F4] d    h T_3_F4_ i(T_3[A5] e    h T_3_A5_ i(T_3[D5] f    h T_3_D5_ i(T_3[E5] g    h T_3_E5_ i(T_3[F5] h    h T_3_F5_ i(T_3[A6] i    h T_3_A6_ i(T_3[D6]! j    h T_3_D6_! i(T_3[E6]" k    h T_3_E6_" i(T_3[F6]# l    h T_3_F6_# i(T_3[F7]) m    h T_3_F7_) i(T_6[B2] n    h T_6_B2_ i(T_6[C2] o    h T_6_C2_ i(T_6[B3] p    h T_6_B3_ i(T_6[C3] q    h T_6_C3_ i(T_6[B4] r    h T_6_B4_  i(T_6[C4] s    h T_6_C4_  i'NoDays t    h NODAYS i+PerDiemAmt u    h  PERDIEMAMT i%NFC1 v    h NFC1 i)NoTrvlrs w    h NOTRVLRS i+ActSubsAmt x    h  ACTSUBSAMT i%nfc2 y    h NFC2 i&Rate1 z    h RATE1 i'Miles1 {    h MILES1 i&Rate2 |    h RATE2 i'Miles2 }    h MILES2 i&Rate3 ~    h RATE3 i'Miles3     h MILES3 i&Rate4     h RATE4 i'Miles4     h MILES4 i)MilesAmt     h MILESAMT i%NFC3     h NFC3 i*ParkngAmt     h PARKNGAMT i%NFC4     h NFC4 i(PlanBus     h PLANBUS i%NFC5     h NFC5 i*UnaccmBag     h UNACCMBAG i%NFC6     h NFC6 i*LoclTrnsp     h LOCLTRNSP i%NFC7     h NFC7 i*MiscExpns     h MISCEXPNS i%NFC8     h NFC8 i)CarRentl     h CARRENTL i%NFC9     h NFC9 i)total_wt     h TOTAL_WT i*ShipGoods     h SHIPGOODS i&nfc10     h NFC10 i*total_wt2     h TOTAL_WT2 i(No_days     h NO_DAYS i)first_30     h FIRST_30 i&nfc11     h NFC11 i(over_30     h OVER_30 i&nfc12     h NFC12 i)No_days2     h NO_DAYS2 i'No_occ     h NO_OCC i*TempQrtrs     h TEMPQRTRS i&nfc13     h NFC13 i*reloc_tax     h RELOC_TAX i&nfc14     h NFC14 i*TotlClaim     h TOTLCLAIM i&nfc15     h NFC15 i+TrvlAdvnce     h  TRVLADVNCE i&NFC16     h NFC16 i+OutstdgAdv     h  OUTSTDGADV i&NFC17     h NFC17 i+BillCollct     h  BILLCOLLCT i&NFC18     h NFC18 i'BillNo     h BILLNO i*BillNoAmt     h BILLNOAMT i&NFC19     h NFC19 i'AddAdv     h ADDADV i&NFC20     h NFC20 i*RemainAdv     h REMAINADV i&NFc21     h NFC21 i*NetTravlr     h NETTRAVLR i&NFC22     h NFC22 i(AUDITBY     h AUDITBY i*TotalDiff     h TOTALDIFF i*AuthAcctg      h AUTHACCTG  i+DistAcctng      h  DISTACCTNG  i(T_4[A1]     h T_4_A1_ i(T_4[B1]  A   h T_4_B1_A i(T_4[C1]     h T_4_C1_ i(T_4[A2]     h T_4_A2_ i(T_4[B2]  A   h T_4_B2_A i(T_4[C2]     h T_4_C2_ i(T_4[A3]     h T_4_A3_ i(T_4[B3]  A   h T_4_B3_A i(T_4[C3]     h T_4_C3_ i(T_4[A4]     h T_4_A4_  i(T_4[B4]  A   h T_4_B4_ A i(T_4[C4]     h T_4_C4_  i(T_4[A5]     h T_4_A5_  i(T_4[B5]  A   h T_4_B5_ A i(T_4[C5]     h T_4_C5_ i(T_4[A6]     h T_4_A6_ i(T_4[B6]  A   h T_4_B6_A i(T_4[C6]     h T_4_C6_ i(T_4[A7]     h T_4_A7_ i(T_4[B7]  A   h T_4_B7_A i(T_4[C7]     h T_4_C7_ i*ClaimSign  8   h CLAIMSIGN8 i+ClaimSDate     h  CLAIMSDATE i+FinlIndctr     h  FINLINDCTR i*ApprvSign  8   h APPRVSIGN8 i%ssn2     h SSN2 i)ApprName  8   h APPRNAME8 i(ApprAgy     h APPRAGY i*DateApprv     h DATEAPPRV i&phone     h PHONE i+ContctName  #   h  CONTCTNAME# i+CntctPhone     h  CNTCTPHONE i%ssn3     h SSN3 i+TrvlrName2  n   h  TRVLRNAME2n i(T_8[A1]     h T_8_A1_ i(T_8[A2]     h T_8_A2_ i(T_8[A3]     h T_8_A3_ i(T_8[A4]     h T_8_A4_ i(T_8[A5]     h T_8_A5_ i(T_8[A6]     h T_8_A6_ i(T_8[A7]     h T_8_A7_ i(T_8[A8]     h T_8_A8_ i(T_8[A9]     h T_8_A9_ i)T_8[A10]     h T_8_A10_  i)T_8[A11]     h T_8_A11_  i)T_8[A13]     h T_8_A13_  i)T_8[A15]     h T_8_A15_ i)T_8[A16]     h T_8_A16_ i)T_8[A17]     h T_8_A17_ i)T_8[A18]     h T_8_A18_ i)T_8[A19]     h T_8_A19_ i)T_8[A20]     h T_8_A20_ i)T_8[A21]     h T_8_A21_ i)T_8[A22]     h T_8_A22_ i)T_8[A23]     h T_8_A23_ i)T_8[A24]     h T_8_A24_ i)T_8[A25]     h T_8_A25_ i)T_8[A26]     h T_8_A26_ i)T_8[A27]     h T_8_A27_ i(T_9[A1]     h T_9_A1_ i(T_9[A2]     h T_9_A2_ i(T_9[A3]     h T_9_A3_ i(T_9[A4]     h T_9_A4_ i(T_9[A5]     h T_9_A5_ i(T_9[A6]     h T_9_A6_ i(T_9[A7]     h T_9_A7_ i(T_9[A8]     h T_9_A8_ i(T_9[A9]     h T_9_A9_ i)T_9[A10]     h T_9_A10_  i)T_9[A11]     h T_9_A11_  i)T_9[A13]     h T_9_A13_  i)T_9[A15]     h T_9_A15_ i)T_9[A16]     h T_9_A16_ i)T_9[A17]     h T_9_A17_ i)T_9[A18]     h T_9_A18_ i)T_9[A19]     h T_9_A19_ i)T_9[A20]     h T_9_A20_ i)T_9[A21]     h T_9_A21_ i)T_9[A22]     h T_9_A22_ i)T_9[A23]     h T_9_A23_ i)T_9[A24]     h T_9_A24_ i)T_9[A25]     h T_9_A25_ i)T_9[A26]     h T_9_A26_ i)T_9[A27]     h T_9_A27_ ?%?.i)T_10[A1]     h T_10_A1_ i)T_10[A2]      h T_10_A2_ i)T_10[A3]      h T_10_A3_ i)T_10[A4]      h T_10_A4_ i)T_10[A5]      h T_10_A5_ i)T_10[A6]      h T_10_A6_ i)T_10[A7]     h T_10_A7_ i)T_10[A8]     h T_10_A8_ i)T_10[A9]     h T_10_A9_ i*T_10[A10]     h T_10_A10_  i*T_10[A11]     h T_10_A11_  i*T_10[A13]     h T_10_A13_  i*T_10[A15]     h T_10_A15_ i*T_10[A16]     h T_10_A16_ i*T_10[A17]     h T_10_A17_ i*T_10[A18]     h T_10_A18_ i*T_10[A19]     h T_10_A19_ i*T_10[A20]     h T_10_A20_ i*T_10[A21]     h T_10_A21_ i*T_10[A22]     h T_10_A22_ i*T_10[A23]     h T_10_A23_ i*T_10[A24]     h T_10_A24_ i*T_10[A25]     h T_10_A25_ i*T_10[A26]     h T_10_A26_ i*T_10[A27]      h T_10_A27_ i)T_11[A1] !    h T_11_A1_ i)T_11[A2] "    h T_11_A2_ i)T_11[A3] #    h T_11_A3_ i)T_11[A4] $    h T_11_A4_ i)T_11[A5] %    h T_11_A5_ i)T_11[A6] &    h T_11_A6_ i)T_11[A7] '    h T_11_A7_ i)T_11[A8] (    h T_11_A8_ i)T_11[A9] )    h T_11_A9_ i*T_11[A10] *    h T_11_A10_  i*T_11[A11] +    h T_11_A11_  i*T_11[A13] ,    h T_11_A13_  i*T_11[A15] -    h T_11_A15_ i*T_11[A16] .    h T_11_A16_ i*T_11[A17] /    h T_11_A17_ i*T_11[A18] 0    h T_11_A18_ i*T_11[A19] 1    h T_11_A19_ i*T_11[A20] 2    h T_11_A20_ i*T_11[A21] 3    h T_11_A21_ i*T_11[A22] 4    h T_11_A22_ i*T_11[A23] 5    h T_11_A23_ i*T_11[A24] 6    h T_11_A24_ i*T_11[A25] 7    h T_11_A25_ i*T_11[A26] 8    h T_11_A26_ i*T_11[A27] 9    h T_11_A27_ i)T_12[A1] :    h T_12_A1_ i)T_12[A2] ;    h T_12_A2_ i)T_12[A3] <    h T_12_A3_ i)T_12[A4] =    h T_12_A4_ i)T_12[A5] >    h T_12_A5_ i)T_12[A6] ?    h T_12_A6_ i)T_12[A7] @    h T_12_A7_ i)T_12[A8] A    h T_12_A8_ i)T_12[A9] B    h T_12_A9_ i*T_12[A10] C    h T_12_A10_  i*T_12[A11] D    h T_12_A11_  i*T_12[A13] E    h T_12_A13_  i*T_12[A15] F    h T_12_A15_ i*T_12[A16] G    h T_12_A16_ i*T_12[A17] H    h T_12_A17_ i*T_12[A18] I    h T_12_A18_ i*T_12[A19] J    h T_12_A19_ i*T_12[A20] K    h T_12_A20_ i*T_12[A21] L    h T_12_A21_ i*T_12[A22] M    h T_12_A22_ i*T_12[A23] N    h T_12_A23_ i*T_12[A24] O    h T_12_A24_ i*T_12[A25] P    h T_12_A25_ i*T_12[A26] Q    h T_12_A26_ i*T_12[A27] R    h T_12_A27_ i)T_13[A1] S    h T_13_A1_ i)T_13[A2] T    h T_13_A2_ i)T_13[A3] U    h T_13_A3_ i)T_13[A4] V    h T_13_A4_ i)T_13[A5] W    h T_13_A5_ i)T_13[A6] X    h T_13_A6_ i)T_13[A7] Y    h T_13_A7_ i)T_13[A8] Z    h T_13_A8_ i)T_13[A9] [    h T_13_A9_ i*T_13[A10] \    h T_13_A10_  i*T_13[A11] ]    h T_13_A11_  i*T_13[A13] ^    h T_13_A13_  i*T_13[A15] _    h T_13_A15_ i*T_13[A16] `    h T_13_A16_ i*T_13[A17] a    h T_13_A17_ i*T_13[A18] b    h T_13_A18_ i*T_13[A19] c    h T_13_A19_ i*T_13[A20] d    h T_13_A20_ i*T_13[A21] e    h T_13_A21_ i*T_13[A22] f    h T_13_A22_ i*T_13[A23] g    h T_13_A23_ i*T_13[A24] h    h T_13_A24_ i*T_13[A25] i    h T_13_A25_ i*T_13[A26] j    h T_13_A26_ i*T_13[A27] k    h T_13_A27_ i)T_14[A1] l    h T_14_A1_ i)T_14[A2] m    h T_14_A2_ i)T_14[A3] n    h T_14_A3_ i)T_14[A4] o    h T_14_A4_ i)T_14[A5] p    h T_14_A5_ i)T_14[A6] q    h T_14_A6_ i)T_14[A7] r    h T_14_A7_ i)T_14[A8] s    h T_14_A8_ i)T_14[A9] t    h T_14_A9_ i*T_14[A10] u    h T_14_A10_  i*T_14[A11] v    h T_14_A11_  i*T_14[A13] w    h T_14_A13_  i*T_14[A15] x    h T_14_A15_ i*T_14[A16] y    h T_14_A16_ i*T_14[A17] z    h T_14_A17_ i*T_14[A18] {    h T_14_A18_ i*T_14[A19] |    h T_14_A19_ i*T_14[A20] }    h T_14_A20_ i*T_14[A21] ~    h T_14_A21_ i*T_14[A22]     h T_14_A22_ i*T_14[A23]     h T_14_A23_ i*T_14[A24]     h T_14_A24_ i*T_14[A25]     h T_14_A25_ i*T_14[A26]     h T_14_A26_ i*T_14[A27]     h T_14_A27_ i)PDiemDay     h PDIEMDAY i*lodg_totl     h LODG_TOTL i*PDiemTotl     h PDIEMTOTL i*MilesTotl     h MILESTOTL i)MAmtTotl     h MAMTTOTL i*ParkgTotl     h PARKGTOTL i+PlnBusTotl     h  PLNBUSTOTL i*UnAccTotl     h UNACCTOTL i)SubsTotl     h SUBSTOTL i)MiscTotl     h MISCTOTL i(CarTotl     h CARTOTL i)wt_goods     h WT_GOODS i*comm_rate     h COMM_RATE i&total     h TOTAL i*add_allow     h ADD_ALLOW i)LoclTotl     h LOCLTOTL i*DaysClaim     h DAYSCLAIM i*wt_goods2     h WT_GOODS2 i)ActChrgs     h ACTCHRGS i+ComRateChg     h  COMRATECHG i)ClaimAmt     h CLAIMAMT i(days_30     h DAYS_30 i)over_302     h OVER_302 i(REMARKS      h REMARKS  ?@de @?N X T$& 0      P    ,,%, 2   TRAVEL VOUCHER         (Relocation)  P !"#                            <      ^&% & SECTION A -- IDENTIFICATION O !"#                            <  <&    ^^: d 1. TRAVEL AUTHORIZATION NO.: TRVLAUTH!"-./56789:;>?@ABCG                         < #     $     '   Y@$.,! *  < &&  = &&     jx d 2. SOCIAL SECURITY NO.x SSN!"-./567 89: ;>?@ABCG                         < #     $     '    Y@$.,! *  < &&  = &      V        <     V        <    lZ  d 3. NAME (Last)Z LName!"-./56789:;>?@ABCG                         < #     $     '  - -   Y@$.,! *  < &&  = &     djl d (First)l FName!"-./546789:;>?@ABCG                         < #     $     '  - -   Y@$.,! *  < &&  = &&     r d (Middle Initial) MiddleName!"- ./5C6789:;>?@ABCG                         < #     $     '  - -   Y@$.,! *  < &  = &&     "  d 4. AGENCY  d  CODE I !"#      U                      <  && &    ?" AgyCode!"- ./5I6789:;>?@ABCG                         < #    Z $    Z '  - -   Y@$.,! *  < & & = &&     1^~:X: ^ORGOFCNO!"- ./56789:;>?@ABCG                         < #     $     '   Y@$.,! *  < && = &&     ^~:  d 5. AGENCY ORIGINATING OFFICE  d  NUMBER  !"#      U                      <  && &    ~, d 6. TRAVELER ORIGINATING  d  OFFICE NUMBER  !"#      U                      <  && &    3~X ^TrvlrOfcNo!"-./56789:;>?@ABCG                         < #     $     '   Y@$.,! *  < && = &&     <~ d 7. DATES OF TRAVEL EXPENSES   !"#                            <  &&     < d1 FROM T1# $(), -. /01 2456789                                  < ! h"$%&')*                     Y@$.,!  ( &&&& 3 &&&&    A     A     ?    ?    ?    @ dP Month"$}%&')*                      Y@$.,!  (     > d| Day"$}%&')*                      Y@$.,!  (     ? do Year"$}%&')*                      Y@$.,!  (     NTravelFrm"$% &')*                     Y@$.,  !  (      D"$%&')*                     Y@$.,  !  (     B"$%&')*                     Y@$.,  !  (      d8 THRU T2# $(),--. /01 2456789                                  < ! h"$%&')*                     Y@$.,!  ( &&&& 3 &&&&    A     A     ?    ?    ?    @ dP Month"$}%&')*                      Y@$.,!  (     > d| Day"$}%&')*                      Y@$.,!  (     ? do Year"$}%&')*                      Y@$.,!  (     MTravelTo"$% &')*                     Y@$.,  !  ( &     D"$%&')*                     Y@$.,  !  (     B"$%&')*                     Y@$.,  !  (      V       <     V$,       <     V0, !      <     V , "      <     V, #      <    "~X$ d 9. RECLAIM  d  AMOUNT  d  INCLUDED I !"#      U                      <  && &    ~% d 8. TYPE CLAIM (Indicate one type only) 9 !"#                            <  && &    kr& d HH  d TS  d RC  d RI <  !"#      Z                      <  &&    8x' d = Hsehunting  d = Trans Stn  d = Relo Contr  d = RIT >  !"#      Z                      <      2B TYPECLAIM! "-(./596789:;>?@ABCG                         < #     $     '   Y@$.,! *  < &&&& = &    2" AMT8! "-)./5I6789:;>?@ABCG                         < #     $     '     $.,! *  < &&& = &&     ^ %* & SECTION B -- TRAVEL VOUCHER MAILING ADDRESS OPTIONS  O !"#                            <  <&    ^+ & SECTION E -- ACCOUNTING CLASSIFICATION !0 !"#                            <  <&    ^3', & SECTION F -- CERTIFICATION 20 !"#                            <  <&    ^ (&- }  FRAUDULENT CLAIM. Falsification of an item in an expense account will result in a forfeiture of the claim (28 USC  } 2514) and may result in a fine of not more than $10,000 or imprisonment for not more than 5 years or both (18 USC 287;  } i.d. 1001). 30 !"#      _                      <  &&$    ?? O ^) . }  CLAIMANT'S RESPONSIBILITIES AND SIGNATURE. I hereby assign to the United States any rights I may have  } against other parties in connection with any reimbursable carrier transportation charges described herein. I have  } received no payment for claims shown herein. All travel and reimbursable claims were incurred on official business of  } the United States Government. All tickets, coupons, promotional items and credits received in connection with travel  } claimed on this voucher have been accounted for as required by FPMR 101-7 and other regulations. I have reviewed this  } voucher and certify it to be correct. 50 !"#      _                      <  &&     [^,>  d 52. CLAIMANT'S SIGNATURE> ClaimSign!f"-/./569789:;>?@ABCG                         < #     $     ' 8  Y@$.,! *  < &&  = &&    l,0 d 53. DATE 9  !"#                            <  && &    ^|.1 }  APPROVING OFFICER'S RESPONSIBILITIES AND SIGNATURE. In approving this voucher, I have determined that: (1)  q Reimbursement is claimed for official travel only; (2) Use of rental car, taxicab, or other special conveyance for whichreimbursement is  q claimed is to the Government's advantage; and (3) Long distance phone calls and supplies or equipment purchased are necessary and in the  q interest of the Government. Note: To approve long distance phone calls, approving officer must have written authorization from Agency  q Head or his /her designee (31 USC 1348).  ;0 !"#      _                      <  &&    H- ClaimSDate!g"-2./56:7 89:;>?@ABCG                         < #     $     '   @$.,  ! *  < &&&& = `     i\-~3 d: Month : !"#                            <      g\-4 dg Day ": !"#                            <      h]\-5 du Year %: !"#                            <       V- 6      <     Vb- 7      <    O,8 d 54. FINAL VOUCHER  d  INDICATOR )9  !"#      P                      <  && &    -O- FinlIndctr!h"-9./5)6:789:;>?@ABCG                         < #     $     '   Y@$.,! *  < &&&& = &&     j-: d N = No 0: !"#                            <      k-; d Y = Yes ,: !"#                            <       V`- <      <    5l  DutyStatn!"-A./5&6 789:;>?@ABCG                         < #     $     '   Y@$.,! *  < && = &&      B d 12. OFFICIAL DUTY STATION CITY AND STATE & !"#      d                      <  && &     C d 13. RESIDENT CITY AND STATE (If other than official station) : !"#      d                      <  & &    /l  ResdStatn!"-D./5:6 789:;>?@ABCG                         < #     $     '   Y@$.,! *  < &&&& = &&     f^ d 15. NUMBER OF NIGHTS IN APPROVED ACCOMMODATIONS PER THE FIRE SAFETY ACT STANDARDS NightApprv!"-E./5&6 7+89:+;>?@ABCG                         < #     $     ' K   $.,! *  < &&  = &&     \f` ^ d 14. TOTAL NIGHTS LODGING` TotlLodg!"-F./56 789:;>?@ABCG                         < #     $     '    $.,! *  < &&  = &&     ^G & SECTION C -- TRANSPORTATION COSTS 0 !"#                            <  &&    ^H d 20.  d0 METHOD OF  dn PAYMENT  !"#      U                       <      I d 21.  d{ VENDOR/  d{ CARRIER  !"#      U                       <      @J d 22.  d IDENTIFICATION  dC NUMBER   !"#      U                       <      z K d< 23. CAR RENTAL  !"#      U                       <      q bL dO MILES  !"#      U                       <      pbM d\ DAYS  !"#      U                       <      N d 24.  d AMOUNT #  !"#      U                       <      ^*xT 1 T_1#$(O),-.,/012456789                                    < ! ("$%&')*                       Y@$.,!  (  3     A     A     A     A     A     A     A     ?    ?    ?@     ?    ?    ?     *"P$%&')*                       Y@$.,!  (     *"Q$%&')*                       Y@$.,!  (     *@"R$% &')*                      Y@$.,!  (     *"S$%&')*                       @$.,!  (     *"T$%&')*                       @$.,!  (     ,"U$% &')*                        $.,!  ( x&&    *"V$%&')*                       Y@$.,!  (     *"W$%&')*                       Y@$.,!  (     *@"X$% &')*                      Y@$.,!  (     * "Y$%&')*                       @$.,!  (     * "Z$%&')*                       @$.,!  (     , "[$% &')*                        $.,!  ( x&&    * "\$%&')*                       Y@$.,!  (     * "]$%&')*                       Y@$.,!  (     ? ?O*@"^$% &')*                      Y@$.,!  (     *"_$%&')*                       @$.,!  (     *"`$%&')*                       @$.,!  (     ,"a$% &')*                        $.,!  ( x&&    *"b$%&')*                       Y@$.,!  (     *"c$%&')*                       Y@$.,!  (     *@"d$% &')*                      Y@$.,!  (     *"e$%&')*                       @$.,!  (     *"f$%&')*                       @$.,!  (     ,"g$% &')*                        $.,!  ( x&&    *"h$%&')*                       Y@$.,!  (     *"i$%&')*                       Y@$.,!  (     *@"j$% &')*                      Y@$.,!  (     *"k$%&')*                       @$.,!  (     *"l$%&')*                       @$.,!  (     ,"m$% &')*                        $.,!  ( x&&    *"n$%&')*                       Y@$.,!  (     *"o$%&')*                       Y@$.,!  (     *@ "p$% &')*                      Y@$.,!  (     *!"q$%&')*                       @$.,!  (     *""r$%&')*                       @$.,!  (     ,#"s$% &')*                        $.,!  ( x&&    *$"t$%&')*                       Y@$.,!  (     *%"u$%&')*                       Y@$.,!  (     *@&"v$% &')*                      Y@$.,!  (     *'"w$%&')*                       @$.,!  (     *("x$%&')*                       @$.,!  (     ,)"y$% &')*                        $.,!  ( x&&    g*^z d $ # !"#                             <      ^ ,{ & If payment was made by traveler,  & complete Section G on reverse.  !"#      P                       <      jN | d 1   !"#                             <      j`  ,} } TOTALS  !"#                            <  &&&     . ,T 2 T_2#$(~),-./012456789                                    < ! h,"5$%&')*                      Y@$.,!  (  3     A,     ?    ?    ?     ,,"$%&')*                      A$.,!  (     @SUM(T_1[D1..D7])  T_1'    k  .,"$%&')*                       A$.,!  (     @SUM(T_1[E1..E7])  T_1(    k  .,"$% &')*                      !<6 !<6G$.,!  ( x&&    @SUM(T_1[F1..F7])  T_1)    k  g^ d $ # !"#                             <      uD  d  LOCATION / !"#      U                       <      r! d{ AMOUNT H  !"#      U                       <       dP NO. OF  du DAYS C !"#      U                       <      nFb d ST @ !"#      d                       <      qDb d CITY  / !"#      d                       <      D6T 3 T_3##$(),/-."/012456789                                    < ! "6$%&')*                       Y@$.,!  (  3     A     A     A     A     A     A     A,     ?    ?    ?    ?    ?    ?     ,"$%&')*                      Y@$.,!  (     .D"$% &')*                      Y@$.,!  (     ,"$%&')*                      Y@$.,!  (     *"$%&')*                      Y@$.,!  (     *"$%&')*                      @$.,!  (     ,"$% &')*                        $.,!  ( xl&&    ,"$%&')*                      Y@$.,!  (     .D"$% &')*                      Y@$.,!  (     ,"$%&')*                      Y@$.,!  (     ?{?O* "$%&')*                      Y@$.,!  (     * "$%&')*                       @$.,!  (     , "$% &')*                        $.,!  ( &l&&    , "$%&')*                      Y@$.,!  (     .D "$% &')*                      Y@$.,!  (     ,"$%&')*                      Y@$.,!  (     *"$%&')*                      Y@$.,!  (     *"$%&')*                       @$.,!  (     ,"$% &')*                        $.,!  ( &l&&    ,"$%&')*                      Y@$.,!  (     .D"$% &')*                      Y@$.,!  (     ,"$%&')*                      Y@$.,!  (     *"$%&')*                      Y@$.,!  (     *"$%&')*                       @$.,!  (     ,"$% &')*                        $.,!  ( &l&&    ,"$%&')*                      Y@$.,!  (     .D"$% &')*                      Y@$.,!  (     ,"$%&')*                      Y@$.,!  (     *"$%&')*                      Y@$.,!  (     *"$%&')*                       @$.,!  (     ,"$% &')*                        $.,!  ( &l&&    ,"$%&')*                      Y@$.,!  (     .D"$% &')*                      Y@$.,!  (     , "$%&')*                      Y@$.,!  (     *!"$%&')*                      Y@$.,!  (     *""$%&')*                       @$.,!  (     ,#"$% &')*                        $.,!  ( &l&&     , d   TOTAL OUTSIDE CONT. U.S. SUBSISTENCE $"$%&')*                       Y@$.,!  (     0 ,%"$%&')*                       Y@$.,!  (     0 ,&"$%&')*                       Y@$.,!  (     .,'"$%&')*                      Y@$.,!  (     ,,("$%&')*                       @$.,!  (     .,)"$% &')*                        $.,!  ( &l&&    G@sum((t_7[d1]), t_3[f1..f6])   T_7  T_3#    k   V%*       <    g!* d $ H !"#                             <       B & SECTION D -- CLAIMS 3  !"#                            <  &&    x^ dD PURPOSE CODE % !"#      U                       <       d ACCOUNTING CLASSIFICATION  %! !"#      U                       <      v d PERCENTAGE +% !"#      U                       <      ^PT 4 T_4#e$(),-&.0/ 012456789                                    < ! "$% &')*                      Y@$.,!  (  3     A+     A+     A+     A+     A+     A+     AN     ?    ?     ?    *+"$%&')*                       Y@$.,!  (      *+"$% &')*                    A  Y@$.,!  (      *+"$%&')*                     !<6 !<6G$.,!  ( &     *+"$%&')*                       Y@$.,!  (      *+"$% &')*                    A  Y@$.,!  (      *+"$%&')*                     !<6 !<6G$.,!  ( &     *+"$%&')*                       Y@$.,!  (      *+"$% &')*                    A  Y@$.,!  (      *+"$%&')*                     !<6 !<6G$.,!  ( &     *+ "$%&')*                       Y@$.,!  (      *+ "$% &')*                    A  Y@$.,!  (      *+ "$%&')*                     !<6 !<6G$.,!  ( &     *+ "$%&')*                       Y@$.,!  (      *+ "$% &')*                    A  Y@$.,!  (      *+"$%&')*                     !<6 !<6G$.,!  ( &     *+"$%&')*                       Y@$.,!  (      *+"$% &')*                    A  Y@$.,!  (      ??qO*+"$%&')*                     !<6 !<6G$.,!  ( &     *N"$%&')*                       Y@$.,!  (      *N"$% &')*                    A  Y@$.,!  (      *N"$%&')*                     !<6 !<6G$.,!  ( &     g/ }& % 2& !"#                             <      j7&2 } 100% .0 !"#                             <      h7& 2 q THESE PERCENTAGES MUST EQUAL 0 !"#                             <       V ^ ,       <     V r ,       <     V N  ,       <    g  q&     SpeclAddr#$%& ' ()+,-.                            <   !  * &&&& 1  2     3       ? 16. SALARY ADDRESS   !"#                            <  &&      ? 17. T&A CONTACT POINT    !"#                            <  &&    z   ? 18. SPECIAL ADDRESS    !"#                            <  &&    {  q&     ForgnAddr#$% & ' ()+,-.                            <   !  * &&&& 1  2     3     W  c q&     EFTAcct#$%& ' ()+,-.                            <   !  * &&&& 1  2     3     J^T  d 1. (35)& MailAddr1!"-./567089:;>?@ABCG                         < #     $     ' #  Y@$.,! *  < && = &&     J^ | d 2. (35)& |MailAddr2!"-./567089:;>?@ABCG                         < #     $     ' #  Y@$.,! *  < && = &&     N^P  d 3. City (20) MailCity!"-./56789:;>?@ABCG                         < #     $     '   Y@$.,! *  < && = &&     Lk P d State (2)X MailState!"-./567 89:;>?@ABCG                         < #     $     '   Y@$.,! *  < && = &&     M3P d Zip Code (9) MailZip!"-./5$6789:;>?@ABCG                         < #     $     '    Y@$.,! *  < && = &&     jB  X    !"#                             <      j   X    !"#                             <      ja: X "   !"#                             <      j(*  X 7   !"#                             <      j}  X  * !"#                             <        ? 19. TRAVEL EFT ACCOUNT )   !"#                            <  &&    k $ q&     trav_acct#$%'& ' ()+,-.                            <   !  * &&&& 1  2     3      V \ ,       <    ^: d  10. DATE REPORTED AT NEW  d OFFICIAL DUTY STATION  !"#                             P  &&    ^4: d   Month Day Year: REPT_DATE! "-./56 789:;>?@ABCG                         P #      $      '    Y@$.,  ! *  < && = <<      V        P     V        P    Hw, LEAVE LEAVE!"-./56 789:;>?@ABCG                         P #      $      '   Y@$.,! *  < && =       `  d  11. LEAVE TAKEN  !"#                             P  &&    T g d  Y = Yes N = No   !"#                             P  &&    8 BT 5 T_5# $( ),3- ./012456789                                    P ! "$% &')*                      Y@$.,!  ( <<  3 &&    A     A     A     A     A     A     A     A     ?t     ?T    ?z    rt  d  26. TOTAL SALES PRICE OF FORMER RESIDENCE"$%&')*                       Y@$.,!  ( <<     JT d  $"$%&')*                       Y@$.,!  (      ,z"$%&')*                       $.,!  ( <     t  &  27. TOTAL PURCHASE PRICE OF   NEW RESIDENCE "$%&')*                       Y@$.,!  ( <<     JT d  $"$%&')*                       Y@$.,!  (      ,z"$%&')*                       $.,!  ( <     t  d  28. EXPENSES CLAIMED BY RELOCATION SERVICES  d  COMPANY (For Type Claim RC Only, Invoice Attached) "$%&')*                       Y@$.,!  ( <<     LT d  $"$%&')*                       Y@$.,!  (      .z"$%&')*                       $.,!  ( <     .t  "$%&')*                       Y@$.,!  ( <<     .T "$%&')*                       Y@$.,!  (      ??N.z "$%&')*                       $.,!  ( <     ct  d  b. AMENDED VALUE SALES FEE "$%&')*                       Y@$.,!  ( <<     JT d  $ "$%&')*                       Y@$.,!  (      ,z"$%&')*                       $.,!  ( <     ]t  d  c. CANCELLATION FEES"$%&')*                       Y@$.,!  ( <<     JT d  $"$%&')*                       Y@$.,!  (      ,z"$%&')*                       $.,!  ( <     wB q&   EXPENSES CLAIMED BY EMPLOYEE "$%&')*                       Y@$.,!  ( <<     0"$%&')*                       Y@$.,!  ( <<     .z" $%&')*                       $.,!  ( <<     B &  29. OUTSIDE CONT. U.S. SUBSISTENCE   (Type Claim OT Only)" $%&')*                       Y@$.,!  ( <     0" $%&')*                       Y@$.,!  ( <<     .z" $%&')*                       Y@$.,!  ( <<     R  d  a. APPRAISED VALUE SALES FEE 3 !"#                             P  &&    R# out  us out_us!!"-./5L6789:;>?@ABCG                         P #      $      '    Y@$.,! *  < && = <<     ^, d  25. AIRLINE ACCOMMODATIONS 0 !"#                             P  &&    g!^ d $ H !"#                             <       V l:E       P     V  >E       P    0dTf d   Excess fare (Check if applicable)   XCSS_FARE#$%& '()+,-.                             P   !  *  1  2      3     v< d     !"#                             P  &&    vU2 d   $  !"#                             P  &&     q&     DistAcctngd#$%&#'()+,-.                            <   !  *  1  2     3     ,^, }  51. DISTRIBUTED ACCOUNTING  (Check this block and distribute total claim from Section D to the  } applicable Accounting Classification line.) #0 !"#      U                      <  <     V ^^       <     q&     AuthAcctgc#$%&"' ()+,-.                            <   !  *  1  2     3     ^,  }&  50. AUTHORIZATION ACCOUNTING (Check this block if accounting from travel  } authorization is to be charged for the total voucher claim.) "0 !"#      U                      <  <     V ^^ !      <    [^&," 0 !"#                             P  &&    4F T 6 T_6#$$(/),3-./012456789                                    P ! "$% &')*                      Y@$.,!  ( <<  3 &&    A     A     A     A     ?6    ?    ?'    w6 d  30. REAL ESTATE (Paid by Employee)"#$%&')*                       Y@$.,!  ( <<     _ d   AMOUNT "$$%&')*                       Y@$.,!  ( <<     n' d   NFC USE "%$%&')*                       Y@$.,!  ( $$     k6 d a. SALES EXPENSE (AD-424 Attached)"&$}%&')*                       Y@$.,!  ( H<     ,"'$%&')*                       $.,!  ( x<     *'"($%&')*                      $.,!  ( <<     z6 d  b. PURCHASE EXPENSE (AD-424 Attached)")$%&')*                       Y@$.,!  ( H     ,"*$%&')*                       $.,!  ( <<     *'"+$%&')*                      $.,!  ( <<     e6 d  c. LEASE TERMINATION EXPENSE ",$%&')*                       Y@$.,!  ( H<     , "-$%&')*                       $.,!  ( <<     *' ".$%&')*                      $.,!  ( <<     gl 1 d $ E  !"#                             <      w482 d 31. PER DIEM 3# !"#                            <  &&    Ir d No. of Days [^ NoDays!%"-3./566$789:;>?@ABCG                         < #     $     '    @$.,! *  <  = &&    rLs4 d ] LODGING & IE >$ !"#                            <  &    Gl  \/ $ PerDiemAmt!&"-5./5E6#789:;>?@ABCG                         < #     $     '     $.,! *  < &&&& = <<      VW#l  7      <    Ux 48 E$ !"#                             <  &    P d No. of Travelers [  NoTrvlrs!("-:./556%7 89:;>?@ABCG                         < #     $     '    @$.,! *  <  = &&     ??O5l K ActSubsAmt!)"-;./5E6%789:;>?@ABCG                         < #     $     '     $.,! *  < &&&& = <<     /T$& NFC1!'"-<./5M6#789:;>?@ABCG                         < #     $     '    $.,! *  < &&&& = <<&    kJ:= d ] MEALS >% !"#                            <  &    +F Rate1!+"->./5;6&789:;>?@ABCG                         < #     $     '   X@$.,! *  <  = &&     v758? d 32. MILEAGE 3& !"#                            <  && &    lF`@ d Rate [ 9& !"#                             <      uFA d ] Miles [ =& !"#                             <      g! FB d ] D& !"#                             <      ,F^ Miles1!,"-C./5A6&789:;>?@ABCG                         < #     $     '   @$.,! *  < & =      l`D d Rate [ 9' !"#                             <      lr`E d Rate [ 9( !"#                             <      l `F d Rate [ 9) !"#                             <      uG d ] Miles [ =' !"#                             <      urH d ] Miles [ =( !"#                             <      u I d ] Miles [ =) !"#                             <      g! J d ] D' !"#                             <      g! rK d ] D( !"#                             <      g!  L d ] D) !"#                             <      + Rate2!-"-M./5;6'789:;>?@ABCG                         < #     $     '   X@$.,! *  <  = &&     ,E Miles2!."-N./5A6'789:;>?@ABCG                         < #     $     '   @$.,! *  < & =      +r Rate3!/"-O./5;6(789:;>?@ABCG                         < #     $     '   X@$.,! *  <  = &&     ,rE Miles3!0"-P./5A6(789:;>?@ABCG                         < #     $     '   @$.,! *  < & =      +  Rate4!1"-Q./5;6)789:;>?@ABCG                         < #     $     '   X@$.,! *  <  = &&     , E Miles4!2"-R./5A6)789:;>?@ABCG                         < #     $     '   @$.,! *  < & =      8l B MilesAmt!3"-S./5E6&789:;>?@ABCG                         < #     $     '     $.,! *  < &&&& = <<     _@sum((Rate1*Miles1)/100,(Rate2*Miles2)/100,(Rate3*Miles3)/100,(Rate4*Miles4)/100)   Rate1   Miles1    d     Rate2   Miles2    d     Rate3   Miles3    d     Rate4   Miles4    d      k  /T$&B NFC3!4"-T./5M6&789:;>?@ABCG                         < #     $     '    $.,! *  < &&&& = <<&    7!5U d 33. PARKING, TOLLS, ETC. 3* !"#                            <  &&&&    7l ! ParkngAmt!5"-V./5E6*789:;>?@ABCG                         < #     $     '     $.,! *  < &&&& = <<     /T$!& NFC4!6"-W./5M6*789:;>?@ABCG                         < #     $     '    $.,! *  < &&&& = <<&    7!5X d 34. PLANE, BUS, TRAIN (Paid by Traveler) 3+ !"#      d                      <  &&    7"5Y d 35. UNACCOMPANIED BAGGAGE 3, !"#      d                      <  &&    7Z#5Z d 36. LOCAL TRANSPORTATION 3- !"#      d                      <  &&    7"$5,[ d 37. MISCELLANEOUS EXPENSES/  d  ALLOWANCE 3. !"#      d                      <  &&    x4N%8\ d 38. CAR RENTAL 3/ !"#      d                      <  &&    4|.8^] }&W  TOTAL CLAIM  }& (Block 29 thru 42) 3; !"#      d                      <  &&    g4|.,^ d 43. 3; !"#      d                      <  &&    7/9_ d 44. TRAVEL ADVANCE AMOUNT  d  OUTSTANDING 3= !"#      d                      <  &    7j1=` d 45. AMT. OF VOUCHER (Block 43) TO BE  d  APPLIED TO OUTSTANDING ADVANCE  d  (Block 44) 3? !"#      d                      <  &     Vl H& a      <    72>b d 46. AMT. OF VOUCHER (Block 43) TO BE  d  APPLIED TO OUTSTANDING BILL FOR  d COLLECTION 3A !"#      d                      <  &    r748c d BILL NO. 3C !"#      d                      <  &&    7R55d d 47 ADDITIONAL ADVANCE AMOUNT  d  REPAID (Check or Money Order  d  Attached) 3D !"#      d                      <  &    ??N765e d 48 REMAINING ADVANCE BALANCE  d  (Block 43 minus Blocks 45 and 47) 3F !"#      d                      <  &    7r85f }&  NET TO TRAVELER  }& (Block 43 minus Blocks 45 and 46) 3H !"#      d                      <  &&    g7r8,g d 49. 3H !"#      d                      <  &&    5l ! PlanBus!7"-h./5E6+789:;>?@ABCG                         < #     $     '     $.,! *  < &&&& = <<     /T$!& NFC5!8"-i./5M6+789:;>?@ABCG                         < #     $     '    $.,! *  < &&&& = <<&    7l " UnaccmBag!9"-j./5E6,789:;>?@ABCG                         < #     $     '     $.,! *  < &&&& = <<     /T$"& NFC6!:"-k./5M6,789:;>?@ABCG                         < #     $     '    $.,! *  < &&&& = <<&    7l Z# LoclTrnsp!;"-l./5E6-789:;>?@ABCG                         < #     $     '     $.,! *  < &&&& = <<     /T$Z#& NFC7!<"-m./5M6-789:;>?@ABCG                         < #     $     '    $.,! *  < &&&& = <<&    7l "$, MiscExpns!="-n./5E6.789:;>?@ABCG                         < #     $     '     $.,! *  < &&&& = <<     /T$"$&, NFC8!>"-o./5M6.789:;>?@ABCG                         < #     $     '    $.,! *  < &&&& = <<&    6l N% CarRentl!?"-p./5E6/789:;>?@ABCG                         < #     $     '     $.,! *  < &&&& = <<     /T$N%& NFC9!@"-q./5M6/789:;>?@ABCG                         < #     $     '    $.,! *  < &&&& = <<&    9l |.^ TotlClaim!P"-r./5E6;789:;>?@ABCG                         < #     $     '     $.,! *  < &&&& = Z<     @SUM(t_3[f7], t_6[b2..b4],PerDiemAmt,ActSubsAmt,MilesAmt,ParkngAmt,PlanBus,UnaccmBag,LoclTrnsp,MiscExpns,CarRentl, shipgoods, first_30, over_30, tempqrtrs, reloc_tax)  T_3)  T_6 !  PerDiemAmt !  ActSubsAmt   MilesAmt    ParkngAmt   PlanBus    UnaccmBag    LoclTrnsp    MiscExpns   CarRentl    ShipGoods   first_30   over_30    TempQrtrs    reloc_tax    k  2T$|.&^ nfc15!Q"-s./5M6;789:;>?@ABCG                         < #     $     '    $.,! *  < &&&& = <<&    `@SUM(NFC1,NFC2,NFC3,NFC4,NFC5,NFC6,NFC7,NFC8,NFC9,NFC10,NFC11,NFC12, NFC13, NFC14)   NFC1   nfc2   NFC3   NFC4   NFC5   NFC6   NFC7   NFC8   NFC9   nfc10   nfc11   nfc12   nfc13   nfc14    k  8l / TrvlAdvnce!R"-t./5E6=789:;>?@ABCG                         < #     $     '     $.,! *  < &&&& = <<     0T$/& NFC16!S"-u./5M6=789:;>?@ABCG                         < #     $     '    $.,! *  < &&&& = <<&    8l j1 OutstdgAdv!T"-v./5E6?789:;>?@ABCG                         < #     $     '     $.,! *  < &&&& = <<     0S$j1' NFC17!U"-w./5M6?789:;>?@ABCG                         < #     $     '    $.,! *  < &&&& = <<&    8l 2 BillCollct!V"-x./5E6A789:;>?@ABCG                         < #     $     '     $.,! *  < &&&& = <<     0U$2% NFC18!W"-y./5M6A789:;>?@ABCG                         < #     $     '    $.,! *  < &&&& = <<&    ,4 BillNo!X"-z./596C7 89:;>?@ABCG                         < #     $     '   Y@$.,! *  < &&&& = &&     j4{ X 7  7C !"#                             <  &    7l 4 BillNoAmt!Y"-|./5E6C789:;>?@ABCG                         < #     $     '     $.,! *  < &&&& = <<     0T$4& NFC19!Z"-}./5M6C789:;>?@ABCG                         < #     $     '    $.,! *  < &&&& = <<&    4l R5 AddAdv!["-~./5E6D789:;>?@ABCG                         < #     $     '     $.,! *  < &&&& = <<     0T$R5& NFC20!\"-./5M6D789:;>?@ABCG                         < #     $     '    $.,! *  < &&&& = <<&    9l 6 RemainAdv!]"-./5E6F789:;>?@ABCG                         < #     $     '     $.,! *  < &&&& = <<     <@SUBTRACT (@SUM(OutstdgAdv,AddAdv),TrvlAdvnce) !  OutstdgAdv   AddAdv    k !  TrvlAdvnce      2O$6+ NFc21!^"-./5M6F789:;>?@ABCG                         < #     $     '    $.,! *  < &&&& = <<&    2@SUBTRACT (NFC17,@SUM (NFC20,NFC15))   NFC17   NFC20   nfc15    k      9l r8 NetTravlr!_"-./5E6H789:;>?@ABCG                         < #     $     '     $.,! *  < &&&& = Z<     @@SUBTRACT (@SUM(OutstdgAdv,Billcollct),TrvlAdvnce) !  OutstdgAdv !  BillCollct    k !  TrvlAdvnce      2O$r8+ NFC22!`"-./5M6H789:;>?@ABCG                         < #     $     '    $.,! *  < &&&& = <<&    2@SUBTRACT (NFC17,@SUM (NFC18,NFC15))   NFC17   NFC18   nfc15    k      ?? Ogl . d $ E< !"#                             <  &    gl 9w d $ EI !"#                             <  &    Wl : d TOTAL DIFFERENCE TotalDiff!b"-./5E6J7 89: ;>?@ABCG                         < #     $     '    $.,! *  < && = &&     !TotlClaim-NetTravlr    TotlClaim    NetTravlr    L7:5 d AUDITED BY 5 AUDITBY!a"-./536J789:;>?@ABCG                         < #     $     '   Y@$.,! *  < && = &&     /T$& nfc2!*"-./5M6%789:;>?@ABCG                         < #     $     '    $.,! *  < &&&& = <<&     VD,       P    4,8 d 42. RELOCATION INCOME TAX  d  (AD-1000 Attached) 39 !"#      d                      <  &    7l , reloc_tax!N"-./5E69789:;>?@ABCG                         < #     $     '     $.,! *  < &&&& = <<     0T$,& nfc14!O"-./5M69789:;>?@ABCG                         < #     $     '    $.,! *  < &&&& = <<&    7&5 d  39. SHIPMENT OF HOUSEHOLD GOODS 30 !"#                             P  &&    O&: d Total Weight [ total_wt!A"-./57617 89:;>?@ABCG                         < #     $     '    @$.,! *  <  = &&     f" &K d ]  D1 !"#                            <      7l & ShipGoods!B"-./5E60789:;>?@ABCG                         < #     $     '     $.,! *  < &&&& = <<     0R$&( nfc10!C"-./5M60789:;>?@ABCG                         < #     $     '    $.,! *  < &&&& = <<&    4'8 d  40. STORAGE OF HOUSEHOLD GOODS 32 !"#                             P  &&    [k 'z ? 1ST 30 DAYS first_30!F"-./5E62789:;>?@ABCG                         < #    d $     '     $.,! *  < &&&& = <<    0T$ )&t nfc12!I"-./5M64789:;>?@ABCG                         < #     $     '    $.,! *  < &&&& = <<&    4*8X d  41. TEMPORARY QUARTERS (AD-569  d  attached) 36 !"#                             P  &&    7l *X TempQrtrs!L"-./5E66789:;>?@ABCG                         < #     $     '     $.,! *  < &&&& = <<     0T$*&X nfc13!M"-./5M66789:;>?@ABCG                         < #     $     '    $.,! *  < &&&& = <<&    f (K d ]  D4 !"#                            <      P(  d Total Weight [ total_wt2!D"-./57647 89:;>?@ABCG                         < #     $     '    @$.,! *  <  = &&     L d  SR =  d OT  d = C !"#      Z                       P  &     \ d  Supp RIT  d Outside  d Cont. U.S.  d Transfer E !"#      U                       P  &&    I)E d No. Days [r No_days!E"-./58657 89:;>?@ABCG                         < #     $     '    @$.,! *  <  = &&     f )K d ]  D5 !"#                            <      Me+ d No. of Days [ No_days2!J"-./59677 89:;>?@ABCG                         < #     $     '    @$.,! *  <  = &&     f (,M d ]  D8 !"#                            <      MJ4, d No. Occupants [b No_occ!K"-./58687 89:;>?@ABCG                         < #     $     '    @$.,! *  <  = &&     ^2 d 57. NAME AND TITLE (Last, First, Middle Initial) (Type or Print) ApprName!k"-./56@7*89:*;>?@ABCG                         < #     $     ' 8  Y@$.,! *  < &&  = &&    *|^3 ApprAgy!l"-./5-6A789:;>?@ABCG                         < #     $     '    Y@$.,! *  < &&&& = &&    d^1b d 55. APPROVING OFFICER'S SIGNATUREb ApprvSign!i"-./56>7%89:%;>?@ABCG                         < #     $     ' 8  Y@$.,! *  < &&  = &&     }2 d AGENCY  d CODE -@ !"#      P                      <  && &     V}^3       <    l1x d 56. SOCIAL SECURITY NO.x ssn2!j"-./5'6>7 89: ;>?@ABCG                         < #     $     '    Y@$.,! *  < &&  = &      V1       <     VC1       <    {^&4~ d 58. DATE APPROVED B  !"#                            <  && &    F^4~ DateApprv!m"-./56C7 89:;>?@ABCG                         < #     $     '   @$.,  ! *  < &&&& = `     i^4^ d* Month C !"#                            <      g4^ dV Day C !"#                            <      ?D?*h4 db Year C !"#                            <       V 5       <     V 5       <    V^5 d 60. CONTACT PERSON ContctName!o"-./56D7"89:";>?@ABCG                         < #     $     ' #  Y@$.,! *  < &&  = &&    ra5 d 61. PHONE (Area Code and No.) CntctPhone!p"-./5%6D789:;>?@ABCG                         < #     $     ' () -  Y@$.,! *  < &  = &&    m&4[ d 59. PHONE (Area Code and No.)[ phone!n"-./5 6B7'89:';>?@ABCG                         < #     $     ' () -  Y@$.,! *  < &  = &&    [^F7~ F0 !"#                             P  &&    7 &    Upon completion and approval, submit original voucher to:  G, !"#                             P  &&    Y8  &   U.S. Department of Agriculture  & National Finance Center  & P.O. Box 60000  & New Orleans, LA 70160 H !"#                             P  &&    k; , d  This form was electronically produced by Elite Federal Forms, Inc. 8L !"#                            <  &    ~; d FORM AD - 616R (USDA) (Rev. 11/96) >L !"#                            <  &&&&    Z<, d Exception to SF 1012 approved by GSA 11/20/96 2M !"#                            <  &&&    [k  )q ? OVER 30 DAYS over_30!H"-./5E64789:;>?@ABCG                         < #    d $     '     $.,! *  < &&<& = <<     0T$'&t nfc11!G"-./5M62789:;>?@ABCG                         < #     $     '    $.,! *  < &&&& = <<&     V6;       P    mKF c o d e code!"-./5"6 789:;>?@ABCG                         P #      $      '   Y@$.,! *  < && =        / d   Non-contract (Insert Code) &   !"#                             P      D*6T 7 T_7#"$(),/-."/012456789                                    P ! g"$% &')*                      Y@$.,!  ( <<  3 &&    A     ?    ?    ?    ?     *"$%&')*                      Y@$.,!  ( <<     *"$%&')*                      Y@$.,!  ( <<     *"$%&')*                      Y@$.,!  ( <<     ,"$% &')*                       $.,!  ( x<     f v+K d ]  D7 !"#                            <       V8        P     V `.%9       P    ?=< def g h i j klm =?NU]r d TRAVELER'S NAMEr TrvlrName2!"-./567C89:C;>?@ABCG                         < #     $     ' n  Y@$.,! *  < <& = <&    j^] d SOCIAL SECURITY NO. ssn3!"-./567 89: ;>?@ABCG                         < #     $     '    Y@$.,! *  < && = x&    SSN   SSN  ^% & SECTION G -- SCHEDULE OF EXPENSES AND AMOUNTS CLAIMED O !"#                            <  <&     V        <     V       <    ^X q ITINERARY  q FROM   !"#      d                      <  &&<&    z^E d DATE (Month/Day)   !"#                            <  <&    n^ d CITY   !"#                            <  <&    o^ d STATE    !"#                            <  <&    n^d d TIME    !"#                            <  <&    m^-  qP TO     !"#                            <  &&&&    p^O  d COUNTY   !"#                            <  <&    z^  d DATE (Month/Day)    !"#                            <  <&    n^  d CITY    !"#                            <  <&    o^  d STATE   !"#                            <  <&    n^  d TIME   !"#                            <  <&    r^ q PER DIEM   !"#                            <  &&&&    u^m d NO. OF DAYS   !"#                            <  <&&    ^ d LODGING & INCIDENTAL  d EXPENSES  d (Receipt Required for Lodging)   !"#      U                      <  <&    o^ d MEALS   !"#                            <  <&&&    q^ q MILEAGE   !"#                            <  &&&&    o^ d MILES   !"#                            <  <&    w^ d RATE PER MILE   !"#                            <  <&    x^y d MILEAGE AMOUNT   !"#                            <  <&&&    ~^ d PARKING, TOLLS, ETC.   !"#                            <  <&&&    ^ q PLANE, BUS, TRAIN  }  (Paid By Traveler)    !"#                            <  &&    ^ q LOCAL  q TRANSPORTATION $  !"#      Z                      <  &&&    s^} d NO. TRIPS %  !"#                            <  <&    w^E d DAILY EXPENSE &  !"#                            <  <&    ^  q MISCELLANEOUS  qi EXPENSES/  qC ALLOWANCE '  !"#      Z                      <  &&&    Y^ (  !"#                            <  <&    ^ X  qB CAR RENTAL  }  (Paid by Traveler)  } Receipt and Car Rental  } Agreement Required )  !"#      P                      <  && &    x^-"  d RENTAL EXPENSE +  !"#                            <  <&    z^"  d GASOLINE EXPENSE ,  !"#                            <  <&    ^%  q UNACCOMPANIED  q BAGGAGE  "  !"#                            <  &&     V^-        <     V^%       <     V^%       <     V^%%       <     V^ %       <     V^ %       <     V^%       <     V^#%       <    F^6%  } PRIVACY ACT NOTICE. The following information is provided to comply with the Privacy Act of 1974 (P.L. 93-579). The information requested on this form is required under  } the provisions of 5 USC, Chapter 57 (as amended) and Executive Orders 11609 of July 22, 1971, and 11012 of March 27, 1962, for the purpose of recording travel expenses incurred by  } the employee and to claim other entitlements and allowances as prescribed in the Federal Travel Regulations (41 CFR 301-304). The information contained in this form will be used by  } Federal Agency officers and employees who have a need for such information in the performance of their duties. Information will be transferred to appropriate Federal, State, local or  } foreign agencies, when relevant to civil, criminal, or regulatory investigations or prosecutions or pursuant to a requirement by GSA or such other agency in connection with the hiring or  } firing, or security clearance, or such other investigations of the performance of official duty in Government service. Failure to provide the information required will result in delay or  } suspension of the employee's claim for reimbursement. EO !"#      _                      <  <<     V y >      <     V u@ ?      <    h ,A q&   !"#                            <  &<&&    hH , q&   !"#                            <  &<&&     Vz y        <     V0y !      <     Vy "      <     Vy #      <     VRy $      <     V y %      <     Vz u@ &      <     V0u@ '      <     Vu@ (      <     Vu@ )      <     VRu@ *      <     V u@ +      <    ]!x 2 &K TOTALS  &K Transfer  &k these totals to  & Section D on  &D Voucher Front.  & If additional  &? days are  & required, use  & continuation  & sheet F  !"#                            <  &&&&    ??8OT!x d TOTAL NO. DAYSx PDiemDay! "-3./5F67 89: ;>?@ABCG                         < #     $     '    A$.,! *  < &&& = x    ]@SUM(T_8[a13], T_9[a13], T_10[a13], T_11[a13], T_12[a13], T_13[a13], T_14[a13])  T_8   T_9   T_10   T_11   T_12   T_13   T_14     k  R!Ox d TOTAL MEALSx PDiemTotl! "-5./5F67 89: ;>?@ABCG                         < #     $     '    $.,! *  < &&& = x    W@SUM(T_14[A16],T_13[A16],T_8[A16],T_9[A16],T_10[A16],T_11[A16],T_12[A16])  T_14  T_13  T_8  T_9  T_10  T_11  T_12    k  e!U,7 q& $ F !"#                            <  &&    2 x, SubsTotl!"-:./5F6&7 89:;>?@ABCG                         < #     $     '    $.,! *  < &&&& = x    z@SUM(T_13[A23..a24],T_14[A23..a24],T_8[A23..a24],T_9[A23..a24],T_10[A23..a24],T_11[A23..a24],T_12[A23..a24])  T_13  T_14  T_8  T_9  T_10  T_11  T_12    k   xX; d TOTAL LOCAL  d TRANSPORTATION F$  !"#      Z                      <  &&&    e ,,< q& $ F& !"#                            <  &&    S!vx d TOTAL MILEAGEx MAmtTotl!"->./5F67 89: ;>?@ABCG                         < #     $     '    $.,! *  < && = x    W@SUM(T_13[A19],T_14[A19],T_8[A19],T_9[A19],T_10[A19],T_11[A19],T_12[A19])  T_13  T_14  T_8  T_9  T_10  T_11  T_12    k  R!xX d TOTAL MILESx MilesTotl! "-?./5F67 89: ;>?@ABCG                         < #     $     '    A$.,! *  < && = &&    W@SUM(T_13[A17],T_14[A17],T_8[A17],T_9[A17],T_10[A17],T_11[A17],T_14[A17])  T_13  T_14  T_8  T_9  T_10  T_11  T_14    k  e!>,@ q& $ F !"#                            <  &&     V%> A      <    !xB d TOTAL PLANE, BUS,  d TRAIN F   !"#      Z                      <  &&&    T!x d TOTAL PARKINGx ParkgTotl!"-C./5F67 89: ;>?@ABCG                         < #     $     '    $.,! *  < && = x    W@SUM(T_13[A20],T_14[A20],T_8[A20],T_9[A20],T_10[A20],T_11[A20],T_12[A20])  T_13  T_14  T_8  T_9  T_10  T_11  T_12    k  e!,D q& $ F !"#                            <  &&     V% E      <    e!^,G q& $ F! !"#                            <  &&     V%^ H      <    g x d TOTAL  d MISCELLANEOUSx MiscTotl!"-J./5F6'7 89: ;>?@ABCG                         < #    P $     '    $.,! *  < && = x    W@SUM(T_13[A25],T_14[A25],T_8[a25],T_9[A25],T_10[A25],T_11[A25],T_12[A25])  T_13  T_14  T_8  T_9  T_10  T_11  T_12    k  U! x  d TOTAL CAR RENTALx CarTotl!"-K./5F6)7 89: ;>?@ABCG                         < #     $     '    $.,! *  < && = x    z@SUM(T_13[A26..A27],T_14[A26..A27],T_8[A26..A27],T_9[A26..A27],T_10[A26..A27],T_11[A26..A27],T_12[A26..A27])  T_13  T_14  T_8  T_9  T_10  T_11  T_12    k  !&xL d TOTAL UNACCOMPANIED  d BAGGAGE F"  !"#      Z                      <  &&&    e!,M q& $ F# !"#                            <  &&     V% N      <    3!x UnAccTotl!"-O./5F6#7 89:;>?@ABCG                         < #     $     '    $.,! *  < &&&& = x    W@SUM(T_13[A22],T_14[A22],T_8[A22],T_9[A22],T_10[A22],T_11[A22],T_12[A22])  T_13  T_14  T_8  T_9  T_10  T_11  T_12    k   V%M% Q      <    e ,R q& $ F( !"#                            <  &&     V% S      <    e!",T q& $ F, !"#                            <  &&     V%" U      <    H^)%P  d REMARKS% REMARKS!!"-V./5657O89:O;>?@ABCG                         < #     $     '    Y@$.,! *  < && = x&      V ^]%9 W      <    Y!x d TOTAL LODGING & IEx lodg_totl! "-[./5F67 89: ;>?@ABCG                         < #     $     '    A$.,! *  < &&& = x    Y@SUM(T_8[A15],T_9[A15], T_10[A15], T_11[A15],T_12[A15],T_13[A15],T_14[A15])  T_8  T_9  T_10  T_11  T_12  T_13  T_14    k  e!,\ q& $ F !"#                            <  &&      T_8#$(),-./)012456789                                  < ! "{$%&')*                      Y@$.,!  ( &&&& 3 &&&&    AX     A     A     A     A     A     A     A     A     A     A}     AK     A     AK     A     A     A     A     A     A     A     A     A     A     A     AX     A     ?    9X"$%&')*                      Y@$.,/!  (     ("$%&')*                      Y@$.,!  (     ("$%&')*                      Y@$.,!  (     ("$%&')*                      Y@$.,!  (     ?(?M("$%&')*                      Y@$.,!  (     3"$%&')*                      Y@$.,/!  (     ("$%&')*                      Y@$.,!  (     ("$%&')*                      Y@$.,!  (     ("$%&')*                      Y@$.,!  (     * "$%&')*                       A$.,!  ( &,&&    , "$%&')*                       $.,!  ( &T&&    ,K "$%&')*                       $.,!  ( &T&&    , "$%&')*                       $.,!  ( &T&&    .K "$%&')*                       $.,!  ( &T&&    *"$%&')*                       A$.,!  ( &&&&    *"$%&')*                       A$.,!  ( &&&    ,"$%&')*                       $.,!  ( &T&&    *"$%&')*                       A$.,!  ( &    *" $%&')*                       @$.,!  ( T&    %(T_8[a17]/T_8[a18])/100  T_8  T_8    d    *" $%&')*                       $.,!  ( T&    *" $%&')*                       A$.,!  (     *" $%&')*                       $.,!  ( &T&&    *" $%&')*                       $.,!  ( &T&&    *"$%&')*                       $.,!  ( &T&&    *"$%&')*                       $.,!  ( &T&&    *X"$%&')*                       $.,!  ( &T&&    *"$%&')*                       $.,!  ( &T&&    h, q&  $ !"#                            <  &<&&    h, q&  , !"#                            <  &<&&    hj, q&  4 !"#                            <  &<&&    h , q&  < !"#                            <  &<&&    h, q&  C !"#                            <  &<&&     V Ey       <     Vz Ey       <     V0Ey       <     VEy       <     VEy       <     VREy       <     V Ey       <    ^$^ d TOTAL WEIGHT OF  d GOODS SHIPPED .  !"#                            <  <&    b$r[ d  COMMUTED RATEr comm_rate!"-./56.7 89: ;>?@ABCG                         P #      $      '     A$.,! *  < && = <<     Xz $W U d  TOTALW total!"-./56.789:;>?@ABCG                         P #      $      '     $.,! *  < && = <<      wt_goods*comm_rate   wt_goods    comm_rate    j$. ^ d  ADDITIONAL ALLOWANCES. add_allow!"-./526.789:;>?@ABCG                         P #      $      '     A$.,! *  < && = <<     ^& &   TEMPORARY STORAGE 1 !"#                            <  <&<    Z &  d NUMBER OF  d DAYS  d CLAIMED 1 !"#                            <  <&<    &(  d CLAIM LESSER AMOUNT AND  d DISTRIBUTE TO APPLICABLE PERIOD  d OF STORAGE 01 !"#                            <  `&<    z &  d TOTAL  d WEIGHT  d OF GOODS 1 !"#                            <  <&<    &  d ACTUAL  d CHARGES #1 !"#                            <  `&<    &  d COMMUTED  d RATE  d CHARGES *1 !"#                            <  <&<    e(| q& $ #4 !"#                            <  &&    e( q& $ *4 !"#                            <  &&    e( q& $ 04 !"#                            <  &&     V^%       <     V^%       <     V%F       <     V!       P    hZ n( R `  COMMUTED  ` RATE DaysClaim!"-./563789:;>?@ABCG                         P #      $      '    A$.,! *  < && = <<     hz n( R `  COMMUTED  ` RATE wt_goods2!"-./563789:;>?@ABCG                         P #      $      '    A$.,! *  < && = <<     gn( R `  COMMUTED  ` RATE ActChrgs!"-./5#63789:;>?@ABCG                         P #      $      '    A$.,! *  < && = <<     in( R `  COMMUTED  ` RATE ComRateChg!"-./5*63789:;>?@ABCG                         P #      $      '    A$.,! *  < && = `<     ??Ogpn( R `  COMMUTED  ` RATE ClaimAmt!"-./5263789:;>?@ABCG                         P #      $      '    A$.,! *  < && = <<     W!&x d 1ST 30 DAYS AMOUNTx days_30!"-./5F617 89: ;>?@ABCG                         < #     $     '    $.,! *  < && = x    e![' q& $ F2 !"#                            <  &&     V%j'       <    Y!-(x d OVER 30 DAYS AMOUNTx over_302! "-./5F637 89: ;>?@ABCG                         < #     $     '    $.,! *  < && = x     V%(       <    e!(| q& $ F4 !"#                            <  &&       T_9#$(),-./)012456789                                  < ! "{$%&')*                      Y@$.,!  ( &&&& 3 &&&&    AX     A     A     A     A     A     A     A     A     A     A}     AK     A     AK     A     A     A     A     A     A     A     A     A     A     A     AX     A     ?    9X"$%&')*                      Y@$.,/!  (     ("$%&')*                      Y@$.,!  (     ("$%&')*                      Y@$.,!  (     ("$%&')*                      Y@$.,!  (     ("$%&')*                      Y@$.,!  (     3"$%&')*                      Y@$.,/!  (     ("$%&')*                      Y@$.,!  (     ("$%&')*                      Y@$.,!  (     ("$%&')*                      Y@$.,!  (     * "$%&')*                       A$.,!  ( &,&&    , "$%&')*                       $.,!  ( &T&&    ,K "$%&')*                       $.,!  ( &T&&    , "$%&')*                       $.,!  ( &T&&    .K "$%&')*                       $.,!  ( &T&&    *"$%&')*                       A$.,!  ( &&&&    *"$%&')*                       A$.,!  ( &&&    ,"$%&')*                       $.,!  ( &T&&    *"$%&')*                       A$.,!  ( &    *"$%&')*                       @$.,!  ( T&    %(T_9[A17]/T_9[A18])/100  T_9  T_9    d    *"$%&')*                       $.,!  ( T&    *"$%&')*                       A$.,!  (     *" $%&')*                       $.,!  ( &T&&    *" $%&')*                       $.,!  ( &T&&    *" $%&')*                       $.,!  ( &T&&    *" $%&')*                       $.,!  ( &T&&    *X" $%&')*                       $.,!  ( &T&&    *"$%&')*                       $.,!  ( &T&&    t  T_10#$(),-./)012456789                                  < ! "{$%&')*                      Y@$.,!  ( &&&& 3 &&&&    AX     A     A     A     A     A     A     A     A     A     A}     AK     A     AK     A     A     A     A     A     A     A     A     A     A     A     AX     A     ?    9X"$%&')*                      Y@$.,/!  (     ("$%&')*                      Y@$.,!  (     ("$%&')*                      Y@$.,!  (     ("$%&')*                      Y@$.,!  (     ("$%&')*                      Y@$.,!  (     3"$%&')*                      Y@$.,/!  (     ("$%&')*                      Y@$.,!  (     ("$%&')*                      Y@$.,!  (     ("$%&')*                      Y@$.,!  (     ??O* "$%&')*                       A$.,!  ( &,&&    , "$%&')*                       $.,!  ( &T&&    ,K "$%&')*                       $.,!  ( &T&&    , "$%&')*                       $.,!  ( &T&&    .K "$%&')*                       $.,!  ( &T&&    *"$%&')*                       A$.,!  ( &&&&    *"$%&')*                       A$.,!  ( &&&    ," $%&')*                       $.,!  ( &T&&    *"!$%&')*                       A$.,!  ( &    *""$%&')*                       @$.,!  ( T&    '(T_10[A17]/T_10[A18])/100  T_10  T_10    d    *"#$%&')*                       $.,!  ( T&    *"$$%&')*                       A$.,!  (     *"%$%&')*                       $.,!  ( &T&&    *"&$%&')*                       $.,!  ( &T&&    *"'$%&')*                       $.,!  ( &T&&    *"($%&')*                       $.,!  ( &T&&    *X")$%&')*                       $.,!  ( &T&&    *"*$%&')*                       $.,!  ( &T&&    *  T_11#$(+),&-./)012456789                                  < ! "{$%&')*                      Y@$.,!  ( &&&& 3 &&&&    AX     A     A     A     A     A     A     A     A     A     A}     AK     A     AK     A     A     A     A     A     A     A     A     A     A     A     AX     A     ?    9X",$%&')*                      Y@$.,/!  (     ("-$%&')*                      Y@$.,!  (     (".$%&')*                      Y@$.,!  (     ("/$%&')*                      Y@$.,!  (     ("0$%&')*                      Y@$.,!  (     3"1$%&')*                      Y@$.,/!  (     ("2$%&')*                      Y@$.,!  (     ("3$%&')*                      Y@$.,!  (     ("4$%&')*                      Y@$.,!  (     * "5$%&')*                       A$.,!  ( &,&&    , "6$%&')*                       $.,!  ( &T&&    ,K "7$%&')*                       $.,!  ( &T&&    , "8$%&')*                       $.,!  ( &T&&    .K "9$%&')*                       $.,!  ( &T&&    *":$%&')*                       A$.,!  ( &&&&    *";$%&')*                       A$.,!  ( &&&    ,"<$%&')*                       $.,!  ( &T&&    *"=$%&')*                       A$.,!  ( &    *">$%&')*                       @$.,!  ( T&    '(T_11[A17]/T_12[A18])/100  T_11  T_12    d    *"?$%&')*                       $.,!  ( T&    *"@$%&')*                       A$.,!  (     *"A$%&')*                       $.,!  ( &T&&    *"B$%&')*                       $.,!  ( &T&&    *"C$%&')*                       $.,!  ( &T&&    *"D$%&')*                       $.,!  ( &T&&    *X"E$%&')*                       $.,!  ( &T&&    *"F$%&')*                       $.,!  ( &T&&      T_12#$(G),.-./)012456789                                  < ! "{$%&')*                      Y@$.,!  ( &&&& 3 &&&&    AX     A     A     A     A     A     A     A     A     A     A}     AK     A     AK     A     A     A     A     A     A     A     A     A     A     A     ?N?OAX     A     ?    9X"H$%&')*                      Y@$.,/!  (     ("I$%&')*                      Y@$.,!  (     ("J$%&')*                      Y@$.,!  (     ("K$%&')*                      Y@$.,!  (     ("L$%&')*                      Y@$.,!  (     3"M$%&')*                      Y@$.,/!  (     ("N$%&')*                      Y@$.,!  (     ("O$%&')*                      Y@$.,!  (     ("P$%&')*                      Y@$.,!  (     * "Q$%&')*                       A$.,!  ( &,&&    , "R$%&')*                       $.,!  ( &T&&    ,K "S$%&')*                       $.,!  ( &T&&    , "T$%&')*                       $.,!  ( &T&&    .K "U$%&')*                       $.,!  ( &T&&    *"V$%&')*                       A$.,!  ( &&&&    *"W$%&')*                       A$.,!  ( &&&    ,"X$%&')*                       $.,!  ( &T&&    *"Y$%&')*                       A$.,!  ( &    *"Z$%&')*                       @$.,!  ( T&    '(T_12[A17]/T_12[A18])/100  T_12  T_12    d    *"[$%&')*                       $.,!  ( T&    *"\$%&')*                       A$.,!  (     *"]$%&')*                       $.,!  ( &T&&    *"^$%&')*                       $.,!  ( &T&&    *"_$%&')*                       $.,!  ( &T&&    *"`$%&')*                       $.,!  ( &T&&    *X"a$%&')*                       $.,!  ( &T&&    *"b$%&')*                       $.,!  ( &T&&      T_13#$(c),6-./)012456789                                  < ! "{$%&')*                      Y@$.,!  ( &&&& 3 &&&&    AX     A     A     A     A     A     A     A     A     A     A}     AK     A     AK     A     A     A     A     A     A     A     A     A     A     A     AX     A     ?    9X"d$%&')*                      Y@$.,/!  (     ("e$%&')*                      Y@$.,!  (     ("f$%&')*                      Y@$.,!  (     ("g$%&')*                      Y@$.,!  (     ("h$%&')*                      Y@$.,!  (     3"i$%&')*                      Y@$.,/!  (     ("j$%&')*                      Y@$.,!  (     ("k$%&')*                      Y@$.,!  (     ("l$%&')*                      Y@$.,!  (     * "m$%&')*                       A$.,!  ( &,&&    , "n$%&')*                       $.,!  ( &T&&    ,K "o$%&')*                       $.,!  ( &T&&    , "p$%&')*                       $.,!  ( &T&&    .K "q$%&')*                       $.,!  ( &T&&    *"r$%&')*                       A$.,!  ( &&&&    *"s$%&')*                       A$.,!  ( &&&    ,"t$%&')*                       $.,!  ( &T&&    *"u$%&')*                       A$.,!  ( &    *"v$%&')*                       @$.,!  ( T&    '(T_13[A17]/T_13[A18])/100  T_13  T_13    d    *"w$%&')*                       $.,!  ( T&    *"x$%&')*                       A$.,!  (     *"y$%&')*                       $.,!  ( &T&&    *"z$%&')*                       $.,!  ( &T&&    *"{$%&')*                       $.,!  ( &T&&    *"|$%&')*                       $.,!  ( &T&&    ?? F[=0<(^oZ? F*X"}$%&')*                       $.,!  ( &T&&    *"~$%&')*                       $.,!  ( &T&&    L  T_14# $(),>-./)012456789                                  < ! "{$%&')*                      Y@$.,!  ( &&&& 3 &&&&    AX     A     A     A     A     A     A     A     A     A     A}     AK     A     AK     A     A     A     A     A     A     A     A     A     A     A     AX     A     ?    9X"$%&')*                      Y@$.,/!  (     ("$%&')*                      Y@$.,!  (     ("$%&')*                      Y@$.,!  (     ("$%&')*                      Y@$.,!  (     ("$%&')*                      Y@$.,!  (     3"$%&')*                      Y@$.,/!  (     ("$%&')*                      Y@$.,!  (     ("$%&')*                      Y@$.,!  (     ("$%&')*                      Y@$.,!  (     * "$%&')*                       A$.,!  ( &,&&    , "$%&')*                       $.,!  ( &T&&    ,K "$%&')*                       $.,!  ( &T&&    , "$%&')*                       $.,!  ( &T&&    .K "$%&')*                       $.,!  ( &T&&    *"$%&')*                       A$.,!  ( &&&&    *"$%&')*                       A$.,!  ( &&&    ,"$%&')*                       $.,!  ( &T&&    *"$%&')*                       A$.,!  ( &    *"$%&')*                       @$.,!  ( T&    '(T_14[A17]/T_14[A18])/100  T_14  T_14    d    *"$%&')*                       $.,!  ( T&    *"$%&')*                       A$.,!  (     *"$%&')*                       $.,!  ( &T&&    *"$%&')*                       $.,!  ( &T&&    *"$%&')*                       $.,!  ( &T&&    *"$%&')*                       $.,!  ( &T&&    *X"$%&')*                       $.,!  ( &T&&    *"$%&')*                       $.,!  ( &T&&    4!^x PlnBusTotl!"-./5F6!7 89:;>?@ABCG                         < #     $     '    $.,! *  < &&&& = x    W@SUM(T_13[A21],T_14[A21],T_8[A21],T_9[A21],T_10[A21],T_11[A21],T_12[A21])  T_13  T_14  T_8  T_9  T_10  T_11  T_12    k  $, `  COM ` MUT ` ED  ` RATE wt_goods!"-./5 6/789:;>?@ABCG                         P #      $      '    A$.,! *  < && = <<     U%% & STORAGE OF HOUSEHOLD GOODS 0O !"#                            <  <&    u$d }&  X / !"#                             P      uP $X }&  = / !"#                             P      u%lx }&  + 2/ !"#                             P      u $c }&  = F/ !"#                             P      o!%P q&+ $ F/ !"#                            <       V^)%       <    ^#% & SHIPMENT OF HOUSEHOLD GOODS PAID BY TRAVELER (Weight Certificate or Bill of Lading Required) -O !"#                            <  <&    [!$xV d TOTAL SHIPMENT AMOUNTx LoclTotl!"-I./5F6.7 89: ;>?@ABCG                         < #     $     '    $.,! *  < && = x    $@SUM(total, add_allow)   total    add_allow    k  ?=0defghij =<(defgh <\^o elite10.DLL IVALID FILLER This form was Designed by Elite Federal Forms and requires the Elite/Novell Filler! Call 410-647-9691 for more information. elite10.COM IVALID FILLER This form was Designed by Elite Federal Forms and requires the Elite/Novell Filler! Call 410-647-9691 for more information. WPIN$ELITE10FunctionSet,4.1 ^=Z{j(#lXnZx