Fillable Printable Sf 1164 - Claim For Reimbursement
Fillable Printable Sf 1164 - Claim For Reimbursement
Sf 1164 - Claim For Reimbursement
ACCOUNTING CLASSIFICATION
D. Funeral Honors Detail
A - Local Travel
B - Telephone or Telegraph
C - Other expenses (itemized)
E. Specialty Care
NUMBER OF
MILES
(e)
OPTIONAL FORM 1164 (REV. 11/2017)
8. This claim is approved. Long distance telephone calls, if shown, are certified as
necessary in the interest of the Government. (Note: If long distance calls are
included, the approving official must have been authorized in writing, by the head
of the department or agency to so certify (31 U.S.C. 680a).)
If additional space is required continue on the back.
SUBTOTALS CARRIED FORWARD FROM THE
BACK
TOTALS
10. 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.
DATE
CLAIMANT
SIGN HERE
11. CASH PAYMENT RECEIPT
a. PAYEE (Signature)
b. DATE RECEIVED
c. AMOUNT
12. PAYMENT MADE
BY CHECK NUMBER
Sign Original Only
DATE
Sign Original Only
Sign Original Only
DATE
9. This claim is certified correct and proper for payment.
7. AMOUNT CLAIMED
(Total of columns (f), (g) and (i).)
$
FARE
OR
TOLL
(g)
MILEAGE
(f)
TIPS AND
MISCELLANEOUS
(i)
ADD
PERSONS
(h)
5. PAID BY
Read the Privacy Act Statement on the back of this form.
Show appropriate code in column (b):
MILEAGE RATE
(Enter Whole
Numbers Only)
6. EXPENDITURES
(If fare or toll claimed in column (g) exceeds charge for one person, show in column (h) the number of additional persons which
accompanied the claimant.)
4.
C
L
A
I
M
A
N
T
d. OFFICE TELEPHONE NUMBER
b. EMPLOYEE ID NUMBER
a. NAME (Last, first, middle initial)
c. MAILING ADDRESS (Include ZIP Code)
3. SCHEDULE NUMBER
2. VOUCHER NUMBER1. DEPARTMENT OR ESTABLISHMENT, BUREAU, DIVISION OR OFFICE
CLAIM FOR REIMBURSEMENT
FOR EXPENDITURES
ON OFFICIAL BUSINESS
AMOUNT CLAIMED
(Explain expenditures in specific detail.)
(c) FROM
(a)
(d) TO
DATE
C
O
D
E
(b)
APPROVING
OFFICIAL
SIGN HERE
AUTHORIZED
CERTIFYING
OFFICER
SIGN HERE
$
c
6. EXPENDITURES -- Continued
AMOUNT CLAIMED
DATE
(a)
(c) FROM
C
O
D
E
(b)
D. Funeral Honors Detail
E. Specialty Care
A - Local Travel
B - Telephone or Telegraph
C - Other expenses (itemized)
Show appropriate code in column (b):
(Explain expenditures in specific detail.)
MILEAGE
RATE
NUMBER OF
MILES
(e)
(d) TO
MILEAGE
(f)
FARE
OR
TOLL
(g)
ADD
PERSONS
(h)
TIPS AND
MISCELLANEOUS
(i)
Total each column and enter on the front, subtotal line.
In compliance with the Privacy Act of 1974, the following information is provided: Solicitation of the information on this form is authorized by Executive Order 11609 of July 22, 1971, Executive Order 11012 of March
27, 1962, Executive Order 9397 of November 22, 1943, and 26 U.S.C. 6011(b) and 6109. The primary purpose of the requested information is to determine payment of reimbursements from the Government. The
information will be used by Federal agency officers and employees who have a need for the information in the performance of their official duties. The information may be disclosed to appropriate Federal, State,
Local, or Foreign agencies, when relevant to civil, criminal, or regulatory investigations or prosecutions, or when pursuant to a requirement by this agency in connection with the hiring or firing of an employee, the
issuance of a security clearance, or investigations of the performance of official duty while in Government service. An Employee Identification (ID) Number is solicited under the authority of the Internal Revenue
Code (26 U.S.C. 6011(b) and 6109) and Executive Order 9397, November 22, 1943, for use as a taxpayer and/or identification number. Disclosure is MANDATORY on vouchers claiming payment or reimbursement
which is, or may be, taxable income. Disclosure of your ID Number and other requested information is voluntary in all other instances. Failure to provide the information (other than ID Number) required to support
the claim may result in delay or loss of reimbursement.
OPTIONAL FORM 1164 (REV. 11/2017) BACK
c
