Form Ad 616 R – Fill Out and Use This PDF

SECTION B – TRAVEL VOUCHER MAILING ADDRESS OPTIONS

16. SALARY ADDRESS

17. T&A CONTACT POINT

18. SPECIAL ADDRESS

19. TRAVEL EFT ACCT.

1.(35)

2.(35)

3. City (20)State (2) Zip Code (9)

SECTION C – TRANSPORTATION COSTS

	20.	21.	22.	23. CAR RENTAL		24.
	METHOD OF	VENDOR/	IDENTIFICATION
						AMOUNT
	PAYMENT	CARRIER	NUMBER	MILES	DAYS
						$

	If payment was made by traveler,	TOTALS	$
	complete Section G on reverse.

25. AIRLINE ACCOMMODATIONS
•	Excess fare (Check If Applicable)	•	Non-contract (Insert Code)

SECTION E – ACCOUNTING CLASSIFICATION

50.AUTHORIZATION ACCOUNTING (Check this block if accounting from travel authorization is to be charged for the total voucher claim.)

51.DISTRIBUTED ACCOUNTING (Check this block and distribute total claim from Section D to the applicable Accounting Classification line.)

PURPOSE CODE

ACCOUNTING CLASSIFICATION

PERCENTAGE

%

THESE PERCENTAGES MUST EQUAL 100%

SECTION F – CERTIFICATIONS

FRAUDULENT CLAIM. Falsification of an item in an expense account will result in a forfeiture of the claim (28 USC 2514) and may result in a fine of not more than $10,000 or imprisonment for not more thana 5 years or both (18 USC 287; i.d. 1001). CLAIMANT'S RESPONSIBILITIES AND SIGNATURE. I hereby assign to the United States any rights I may have against other parties in connection with any reimbursable carrier transportation charges described herein. I have received no payment for claims shown herein. All travel and reimbursable claims were incurred on official business of the United States Government. All tickets, coupons, promotional items and credits received in connection with travel claimed on this voucher have been accounted for as required by FPMR 101-7 and other regulations. I have reviewed this voucher and certify it to be correct.

52. CLAIMANT'S SIGNATURE	53. DATE			54. FINAL VOUCHER
	Month	Day	Year	INDICATOR
					Y = Yes	N = No

APPROVING OFFICER'S RESPONSIBILITIES AND SIGNATURE. In approving this voucher, I have determined that: (1) Reimbursement is claimed for official travel only; (2)Use of rental car, taxicab, or other special conveyance for which reimbursement is claimed is to the Government's advantage; and (3) Long distance phone calls and supplies or equipment purchased are necessary and in the interest of the Government. Note: To approve long distance phone calls, approving officer must have written authorization from Agency Head or his/her designee (31 USC 1348).

55. APPROVING OFFICER'S SIGNATURE					56. SOCIAL SECURITY NO.
57. NAME AND TITLE (Last, First, Middle Initial) (Type or Print)							AGENCY
							CODE
58. DATE APPROVED			59. PHONE (Area Code and No.)
Month Day		Year
60. CONTACT PERSON				61. PHONE (Area Code and No.)

Upon completion and approval, submit original voucher to:

U. S. Department of Agriculture

National Finance Center

P. O. Box 60000

New Orleans, LA 70160

SECTION D – CLAIMS

26. TOTAL SALES PRICE OF FORMER RESIDENCE	$
27. TOTAL PURCHASE PRICE OF NEW RESIDENCE	$

28.EXPENSES CLAIMED BY RELOCATION SERVICES COMPANY (For Type Claime RC Only, Invoice Attached)

a. APPRAISED VALUE SALES FEE				$
b. AMENDED VALUE SALES FEE				$
c. CANCELLATION FEES				$
EXPENSES CLAIMED BY EMPLOYEE
29. OUTSIDE CONT. U.S. SUBSISTENCE (Type Claim OT Only)
LOCATION			NO. OF
CITY		ST		AMOUNT
			DAYS
				$

TOTAL OUTSIDE CONT. U.S. SUBSISTENCE							$
30. REAL ESTATE (Paid by Employee)						AMOUNT		USE
a. SALES EXPENSE (AD-424 Attached)					$
b. PURCHASE EXPENSE (AD-424 Attached)
c. LEASE TERMINATION EXPENSE
31. PER DIEM
No. of Days [		] LODGING & IE
No. Travelers [		] MEALS
32. MILEAGE
Rate [	¢]	Miles	[	]
Rate [	¢]	Miles	[	]
Rate [	¢]	Miles	[	]
Rate [	¢]	Miles	[	]
33. PARKING TOLLS, ETC.

34.PLANE, BUS, TRAIN (Paid by Traveler)

35.UNACCOMPANIED BAGGAGE

36.LOCAL TRANSPORTATION

37.MISCELLANEOUS EXPENSES/ ALLOWANCE

38.CAR RENTAL

39.SHIPMENT OF HOUSEHOLD GOODS

Total Weight [		]
40. STORAGE OF HOUSEHOLD GOODS			1ST 30 DAYS
Total Weight [		] OVER 30 DAYS
No. Days [		]
41. TEMPORARY QUARTERS (AD-569
AttachedNo. of Days	[	]
No. of Occupants	[	]
42. RELOCATION INCOME TAX
(AD-1000 Attached)
43.
TOTAL CLAIM
(Block 29 THROUGH 42)		$

44.TRAVEL ADVANCE AMOUNT OUTSTANDING

45.AMOUNT OF VOUCHER (Block 43) TO BE APPLIED TO OUTSTANDING BILL ADVANCE (Block 44)

46.AMOUNT OF VOUCHER (Block 43 TO BE APPLIED TO OUTSTANDING BILL FOR COLLECTION

	BILL NO.
	47. ADDITIONAL ADVANCE AMOUNT
	REPAID (Check or Money Order
	Attached)
	48. REMAINING ADVANCE BALANCE
	(Block 43 Minus Blocks 45 and 47)
	49.
	NET TO TRAVELER	$
	(Block 43 Minus Blocks 45 and 46)
	AUDITED BY	TOTAL DIFFERENCE

SOCIAL SECURITY NO.

TRAVELER'S NAME