Fill and Sign the Power of Attorney Nys Oca Form

Read Privacy Act Statement, Penalty Statement, and Instructions on back before completing form. Use typewriter, ink, or ball point pen. PRESS HARD. DO NOT use pencil. If more space is needed, continue in remarks. TRAVEL VOUCHER OR SUBVOUCHER SPLIT DISBURSEMENT: The Paying Office will pay directly to the Government Travel Charge Card (GTCC) contractor the portion of your reimbursement 1. PAYMENT representing travel charges for transportation, lodging, and rental car if you are a civilian employee, unless you elect a different amount. Military personnel are Electronic Fund required to designate a payment that equals the total of their outstanding government travel card balance to the GTCC contractor. Transfer (EFT) Payment by Check Pay the following amount of this reimbursement directly to the Government Travel Charge Card contractor: $ 2. NAME (Last, First, Middle Initial) (Print or type) 3. GRADE 4. SSN 5. TYPE OF PAYMENT (X as applicable) TDY b. CITY c. STATE d. ZIP CODE e. E-MAIL ADDRESS Member/Employee PCS Other Dependent(s) 6. ADDRESS. a. NUMBER AND STREET DLA 10. FOR D.O. USE ONLY 7. DAYTIME TELEPHONE NUMBER & AREA CODE 8. TRAVEL ORDER/AUTHORIZATION NUMBER 9. PREVIOUS GOVERNMENT PAYMENTS/ ADVANCES a. D.O. VOUCHER NUMBER b. SUBVOUCHER NUMBER 11. ORGANIZATION AND STATION 13. DEPENDENTS' ADDRESS ON RECEIPT OF ORDERS (Include Zip Code) c. PAID BY 14. HAVE HOUSEHOLD GOODS BEEN SHIPPED? (X one) d. COMPUTATIONS 12. DEPENDENT(S) (X and complete as applicable) ACCOMPANIED UNACCOMPANIED a. NAME (Last, First, Middle Initial) b. RELATIONSHIP c. DATE OF BIRTH OR MARRIAGE YES 15. ITINERARY a. DATE c. MEANS/ MODE OF TRAVEL b. PLACE (Home, Office, Base, Activity, City and State; City and Country, etc.) NO (Explain in Remarks) d. REASON FOR STOP e. LODGING COST f. POC MILES DEP ARR DEP ARR DEP ARR DEP ARR DEP ARR DEP e. ARR (1) Per Diem DEP (2) Actual Expense Allowance ARR (3) Mileage 16. POC TRAVEL (X one) OWN/OPERATE PASSENGER 17. DURATION OF TDY TRAVEL 18. REIMBURSABLE EXPENSES a. DATE SUMMARY OF PAYMENT b. NATURE OF EXPENSE c. AMOUNT d. ALLOWED 12 HOURS OR LESS MORE THAN 12 HOURS BUT 24 HOURS OR LESS MORE THAN 24 HOURS (4) Dependent Travel (5) DLA (6) Reimbursable Expenses (7) Total 0.00 (8) Less Advance (9) Amount Owed 0.00 (10) Amount Due 19. GOVERNMENT/DEDUCTIBLE MEALS a. DATE 20.a. CLAIMANT SIGNATURE b. DATE b. NO. OF MEALS a. DATE b. NO. OF MEALS d. DATE c. SUPERVISOR SIGNATURE b. DATE 21.a. APPROVING OFFICER SIGNATURE 22. ACCOUNTING CLASSIFICATION 23. COLLECTION DATA 24. COMPUTED BY 25. AUDITED BY DD FORM 1351-2, JUL 2004 26. TRAVEL ORDER/ AUTHORIZATION POSTED BY 27. RECEIVED (Payee Signature and Date or Check No.) PREVIOUS EDITIONS ARE OBSOLETE. Reset 28. AMOUNT PAID Exception to SF 1012 approved by GSA/IRMS 12-91. PRIVACY ACT STATEMENT AUTHORITY: 5 U.S.C. Section 5701, 37 U.S.C. Sections 404 - 427, 5 U.S.C. Section 301, DoDFMR 7000.14-R, Vol. 9, and E.O. 9397. PRINCIPAL PURPOSE(S): This record is used for reviewing, approving, accounting, and disbursing money for claims submitted by Department of Defense (DoD) travelers for official Government travel. The Social Security number (SSN) is used to maintain a numerical identification filing system for filing and retrieving individual claims. ROUTINE USE(S): Disclosures are permitted under 5 U.S.C. 552a(b), Privacy Act of 1974, as amended. In addition, information may be disclosed to the Internal Revenue Service for travel allowances, which are subject to Federal income taxes, and for any DoD "Blanket Routine Use" as published in the Federal Register. DISCLOSURE: Voluntary; however, failure to furnish the information requested may result in total or partial denial of the amount claimed. PENALTY STATEMENT There are severe criminal and civil penalties for knowingly submitting a false, fictitious, or fraudulent claim (U.S. Code, Title 18, Sections 287 and 1001 and Title 31, Section 3729). INSTRUCTIONS ITEM 1 - PAYMENT ITEM 15 - ITINERARY - SYMBOLS Member must be on electronic funds (EFT) to participate in split disbursement. Split disbursement is a payment method by which you may elect to pay your official travel card bill and forward the remaining settlement dollars to your predesignated account. For example, $250.00 in the "Amount to Government Travel Charge Card" block means that $250.00 of your travel settlement will be electronically sent to the charge card company. Any dollars remaining on this settlement will automatically be sent to your predesignated account. Should you elect to send more dollars than you are entitled, "all" of the settlement will be forwarded to the charge card company. Notification: you will receive your regular monthly billing statement from the Government Travel Charge Card contractor; it will state: paid by Government, $250.00, 0 due. If you forwarded less dollars than you owe, the statement will read as: paid by Government, $250.00, $15.00 now due. Payment by check is made to travelers only when EFT payment is not directed. 15c. MEANS/MODE OF TRAVEL (Use two letters) GTR/TKT or CBA (See Note) Government Transportation Commercial Transportation (Own expense) Privately Owned Conveyance (POC) Automobile Motorcycle Bus Plane Rail Vessel -T -G -C -P - A M B P R V Note: Transportation tickets purchased with a CBA must not be claimed in Item 18 as a reimbursable expense. 15d. REASON FOR STOP Authorized Delay Authorized Return Awaiting Transportation Hospital Admittance Hospital Discharge - AD AR AT HA HD Leave En Route Mission Complete Temporary Duty Voluntary Return - LV MC TD VR REQUIRED ATTACHMENTS 1. Original and/or copies of all travel orders/authorizations and amendments, as applicable. 2. Two copies of dependent travel authorization if issued. 3. Copies of secretarial approval of travel if claim concerns parents who either did not reside in your household before their travel and/or will not reside in your household after travel. 4. Copy of GTR, MTA or ticket used. 5. Hotel/motel receipts and any item of expense claimed in an amount of $75.00 or more. 6. Other attachments will be as directed. ITEM 15e. LODGING COST Enter the total cost for lodging. ITEM 19 - DEDUCTIBLE MEALS Meals consumed by a member/employee when furnished with or without charge incident to an official assignment by sources other than a government mess (see JFTR, par. U4125-A3g and JTR, par. C4554-B for definition of deductible meals). Meals furnished on commercial aircraft or by private individuals are not considered deductible meals. 29. REMARKS a. INDICATE DATES ON WHICH LEAVE WAS TAKEN: b. ALL UNUSED TICKETS (including identification of unused "e-tickets") MUST BE TURNED IN TO THE T/O OR CTO. DD FORM 1351-2 (BACK), JUL 2004 Reset