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STANDARD FORM NO. 1012
GAO $300
TRAVEL VOUCHER
1012-106
DEPARTMENT, BUREAU, OR ESTABLISHMENT
VOUCHER NO.
PAYEE'S NAME
PAID BY
Robert E. Shank, M. D.
MAILING ADDRESS
Dept. of Preventive Medicine
Washington Univ. Medical School
4550 Scott Ave. , St. Louis, Mo.
63110
OFFICIAL DUTY STATION
RESIDENCE
FOR TRAVEL AND OTHER EXPENSES
TRAVEL ADVANCE
CHECK NO.
FROM (DATE)
TO ( DATE)
Outstanding
CASH PAYMENT RECEIVED:
APPLICABLE TRAVEL AUTHORIZATION (S)
Amount to be applied
(DATE)
NO.
DATE
Balance to remain
outstanding
SIGNATURE OF PAYEE)
TRANSPORTATION REQUESTS ISSUED
TRANSPORTATION
AGENT'S
INITIALS OF
MODE, CLASS
POINTS OF TRAVEL
REQUEST NUMBER
VALUATION
CARRIER
ISSUING
OF SERVICE,
TICKET
AND ACCOM-
DATE
OF TICKET
ISSUED
MODATIONS *
FROM-
TO-
GTR - A8 , 779, $90 . 40
EAL
Coach
5/14/67 St. Louis, Mo. Washington, D. C.
154
Washington, D. C.
St. Louis, Mo.
* Certified correct. Payment or credit has not been received.
AMOUNT
Dollars
Cts
6/26/67
CLAIMED
(Date
(Signature of Payee)
APPROVED (Supervisory and other approvals when required )
DIFFERENCES:
VOUCHER NO.
NEXT PREVIOUS VOUCHER PAID UNDER SAME TRAVEL AUTHORITY
D.O. SYMBOL
DATE (MONTH-YEAR)
Total verified correct for charge to appropriation (s)
Certified correct and proper for payment:
Applied to travel advance (appropriation symbol )
NET TO
(Date )
( Authorized Certifying Officer)
TRAVELER
ACCOUNTING CLASSIFICATION ( Appropriation symbol must be shown; other classification optional)
* Abbreviations for Pullman accommodations: MR, master room; DR, drawing room; CP, compartment; BR, bedroom; DSR, duplex single room; RM, roomette;
DRM, duplex roomette; SOS, single occupancy section; LB, lower berth; UB, upper berth; LB-UB, lower and upper berth; S. seat.
DULENT CLAIM-Falsification of an item in an expense account works a forfeiture of the claim (28 U.S.C. 2514 ) and may result in a fine of not more
$10,000 or imprisonment for not more than 5 years or both ( 18 U.S.C. 287; id. 1001).
Source:
://www.industrydocuments.

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