Travel History Sample Form

TRAVEL HISTORY FORM

PRIVACY ACT STATEMENT

Authority: USC 5701,37 USC 404-427, EO 9397, 31 USC 3322, 31 CFR 209 and/or 210.

Principal Purpose(s): Used for reviewing, approving, accounting and disbursing for official travel. SSN is

used to maintain a numerical identification system for individual claims. The

information is confidential and is needed to prove entitlement to payments. The

information will be used to process payment data from the Federal agency to the

financial institution and/or its agent.

Routine Use(s): To substantiate claims for reimbursement for official travel.

Disclosure: Voluntary; however, failure to furnish information requested may result in total or

partial denial of amount claimed and may delay or prevent the receipt of payments

through the EFT/DDS programs.

Name:

Last First Middle Initial

Sponsor's SSN:

Dependent's SSN (If applicable):

Command:

Paygrade: (I..E. E5, O3, GS9)

LOCAL ADDRESS; STREET, CITY, STATE AND ZIP CODE:

CLAIMANT STATUS: (CHECK ONE)

ACTIVE DUTY SEPARATED/RETIRED CIVILIAN EMPLOYEE DEPENDENT

MANDATORY:

FOR EFT/DDS payments please provide the following information:

ACCOUNT TYPE (CHECKING OR SAVINGS)

ACCOUNT NUMBER:

FINANCIAL INSTITUTION NAME:

Financial Institution's 9-DIGIT Routing Transit Number (RTN) available on the bottom of your checks or from your financial

institution:

Signature: Date:

Your WORK phone number: COMM DSN

PSAJAX FORM 7240/10 (Rev. 10/03)

Fillable Printable Travel History Sample Form