Fill and Sign the Nv Affidavit Form

Fact Witness Voucher U.S. Department of Justice Washington, D.C. 20530 THIS IS A 3-PART FORM. FILL OUT FORM AND PRINT 4 COPIES. SIGN AS NEEDED AND ROUTE AS SPECIFIED BELOW. Page 1 of 3 Check One: I [ ] (was) [ ] (was not) a United States citizen at the time of attendance I [ ] (was) [ ] (was not) a Federal Government employee at the time of attendance I [ ] (did) [ ] (did not) receive a cash or check advance. Total advance issued: $ From: _________________________ Witness Name: Court Doc. No: Social Security Number: Case Name: Address: District: City: State: Zip: Court Location: Telephone No. (including area code): GTA [ ] Transportation PART I - Attendance Certification (by Government Official) Object Class (Retention of these fees is considered taxable income and reportable to IRS) A. Amounts (Dollars) (To be completed by US Marshals) UFMS/FMIS Attendance Fees Deposition Dates [ ] Lodging $40 @ days 11804/1126 Grand Jury/Trial Attendance Date (Including Travel) $40 @ days 11804/1156 Pretrial Attendance Dates (Including Travel) $40 @ days 11804/1194 Detained Dates - Citizen/Visitor in Custody $40 @ days 11804/1193 Detained Dates - Deportable Alien in Custody $1 @ days 11804/1195 Total Fees B. Attendance Attestation: I attest that the witness named above attended in the case or matter indicated and is entitled to the statutory allowance for attendance and travel. In proceedings before U.S. Magistrate Judges where more than four witnesses were called, the Magistrate also attests that the approval and certificate of the Litigating Trial Office were first obtained. ________________________________ __________________________________________________ ________________ Signature Title of Authorized Government Official Date This form is continued on Page 2 Original - USMS Trial District Office Copy 1 - Paying Office Copy 2 - DOJ Litigating Trial Office Copy 3 - Witness Previous Editions are Obsolete Form OBD-3 (Revised 4-2013) Fact Witness Voucher U.S. Department of Justice Washington, D.C. 20530 Page 2 of 3 UFMS/FMIS PART II - Allowances C. Travel by Carrier (Receipts required if paid by witness) (DO NOT claim if paid by Government) Check one [ ] Train [ ] Bus [ ] Airplane D. Travel by Privately Owned Vehicle: [ ] Auto/Truck/Van [ ] Motorcycle 21011/2191 2108 [ ] Airplane Round trip mileage @ $ Per mile Total no. of trips Less advance received $ 21015/2192 E. Local Transportation & Other Expenses: (e.g., subway, bus, taxi, tolls, all parking, etc.) (Receipts required for parking and expenses over $25.00) (Gratuities are limited to taxi and shuttle services up to 15%)_ List (item and amount) ______________________________________________________________________________________________ 21001/2193 ______________________________________________________________________________________________ 2133 F. Meals and Lodging: 1. Travel days (½ day’s M&IE per day) @ $ x Day(s) = $ 21013/2194 2. Days away from home (full day’s M&IE per day) @ $ x Day(s) = $ 21013/2194 3. Actual cost of lodging, not to exceed $ @ $ x Day(s) = $ (DO NOT claim if paid by Government) (Receipts are required if paid by witness) Less advance received $ 21012 G. W itness Certification: I certify that this voucher is true and correct to the best of my knowledge and belief, and that payment or credit has not been received by me. (If not a citizen, present your Alien Registration Record with this form) _______________________ Witness Signature ______________ Date _______________________ Alien Registration Record No. H. Claim Verification: Based upon the above information and receipts furnished by the witness, I verify the above information is true and correct to the best of my knowledge. Net Amount Paid _______________________ ______________________________ _____________ Signature Title of Authorized Government Official Date PART III - Certification THIS VOUCHER IS CERTIFIED CORRECT AND PROPER FOR PAYMENT ______________________ ________________________________ Signature ____________ Title of Authorized Certifying Officer PART IV - Disbursement Date (For Finance Office use only) Accounting Classification ___________________________________________________ Check/Draft No. Voucher No. _______________________ ________________________ _____________________________________ _______________ Signature Title of Disbursing Officer Date The Privacy Act Statement and instructions for completion of this form are contained on Page 3 of this form Form OBD-3 (Revised 4-2013) Fact Witness Voucher U.S. Department of Justice Washington, D.C. 20530 Page 3 of 3 INSTRUCTIONS FOR COMPLETING THIS FORM To be completed by the witness 1. At the top of the form, check the appropriate word(s) to indicate if: You were or were not a United States citizen at the time you appeared to testify. If you are not a citizen, you will be required to show proof of your resident or visitor status. You were or were not a federal employee at the time you appeared to testify. The fees and allowances on this form do not apply to federal employees. If you are a federal employee, please request instructions for obtaining reimbursement. You did or did not receive a check or cash advance for your expenses in traveling to court. If you received an advance, enter the amount and issuing office here. Indicate and/or verify your name, Social Security Number, address, and telephone number to ensure that they are correct. This will be the address to which any reimbursement to you for fees or allowances will be mailed. Correct any erroneous information and enter any missing information. SOCIAL SECURITY NUMBER/PRIVACY ACT NOTICE: Disclosure of your social security number is mandatory for Federal income tax reporting purposes under the authority of 26 CFR Section 301-6109-1, in order to ensure the accuracy of income computation by the Internal Revenue Service. This information will be used to identify an individual who is compensated by funds of the Department of Justice. Failure to provide this information may result in delay of your compensation, and the Department of Justice will be required to notify the Internal Revenue Service that your number is unknown. This information is being provided on Form 1099 to the Internal Revenue Service. 2. PART II - Allowances Receipts are required for travel by train, bus or air, all parking, and other single items over $25.00. If you parked at an airport or have not yet paid your hotel/motel bill or other item requiring a receipt, it will be necessary for you to mail your receipts to the trial office. Your claim for reimbursement cannot be processed until you furnish all receipts for expenses that you are claiming on this Fact Witness Voucher. Please note: EXPENSES ASSOCIATED WITH YOUR TRAVEL BY YOUR PRIVATELY OWNED VEHICLE ARE LIMITED TO NO GREATER THAN THE COST OF COACH AIRFARE. The remaining portion of Part II will be completed for you by the Federal government employee assigned to assist you, with the exception of the W itness Certification. G. Witness Certification: Verify that all items under Part II are correct. Any changes to Part II must be effected and signed by the Federal government employee assigned to assist you. Sign you full legal name and the date. If you are not a United States citizen, you will be requested to show proof of your resident or visitor status. Falsification of an item may constitute a forfeiture of claim (28 U.S.C., Section 2514) and may result in a fine of not more than $10,000 or imprisonment of not more than 5 years or both (18 U.S.C. 287). Section B of Part I must be signed by an employee of the office that requested the appearance of the witness. Additionally, Section H of Part II must be signed by an employee of the requesting office attesting to the accuracy and completeness of the expenses claimed by the witness before the form is transmitted to the U.S. Marshals Service for payment. The U.S. Marshals Service will process the Fact Witness Voucher and MAIL payment to you at the address indicated on the first page of this form. If you require funds to return home, you must bring this fact to the attention of the individual assigned to assist you. INSTRUCTIONS TO COMPLETING OFFICE Section H of Part II must be signed by an employee of the office who requested the appearance of this witness, before the form is transmitted to the United States Marshals Service. Any revisions to Part II must be initialed by a Federal government employee. Changes made to Part II by the witness will not be honored. All receipts for claims made in Part II must be attached to the Form OBD-3 before it is transmitted to the United States Marshals Service for payment. Distribution of the Form OBD-3 shall be as follows: The ORIGINAL signed, completed form is retained by the U.S. Marshals Service. One COPY of the signed, completed form is provided to the Paying Office; one COPY is provided to the DOJ Litigating Trial Office; and one COPY is provided to the witness. Form OBD-3 (Revised 4-2013)