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1. DEPARTMENT OR ESTABLISHMENT. BUREAU. DIVISION OR OFFICE
CLAIM FOR REIMBURSEMENT
FOR EXPENDITURES
ON OFFICIAL BUSINESS
2. VOUCHER NUMBER
3. SCHEDULE NUMBER
Read the Privacy Act Statement on the back of this form.
5. PAID BY
.. NAME (lJIs' first middle IntiaI)
b. SOCIAL SECURITY NO.
4.
!i
<II(
::IE
····c. MAILING ADDRESS (lncIur:fg ZIP Code)
d..OFFICE TELEPHONE NUMBER
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6. EXPENDITURES (If fare claimed In col. (g) exceeds charge for one person, show
claimant.)
DATE
19_
In
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col. (h) the number of additional persons which accompanied the
,
Show eppt'(I(Jti8t6 code In COl (b):
AMOUNT CLAIMED
C A-Local travel
0 B-Telephone or telegraph. or
D
MILEAGE
RATE
E c-othEir Expenses (itemized)
¢
(Explain expenditures in specific del8i1.)
(a)
(c) FROM
(b)
MILEAGE
FARE
OR TOLL
ADD,
PER·
SONS
TIPS AND
MISCEL·
LANEOUS
(f)
(g)
(h)
(i)
NO. OF
MILES
(d) TO
(e)
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TOTALS
are
8. This claim is approved. Long distance telephone calls, !f shown,
certified
as necessary in the interest of the Government (Note: Iflong distance calls
tue Incfuded, the spproving officl8l musthave been suthorlzed, In writing. by
the head of the department or sgency to so certify (31
680a).)
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7. AMOUNT CLAIMED (Total of cols. (I), (g) snd (i).)~
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SUBTOTALS CARRIED FORWARD FROM THE
BACK
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H additional space Is required continue on the back.
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10. I certify that this claim is true and correct to the best of my knowledge and
belief and that payment or credit has not been received by me.
u.s.a
Sign Original Only
IDATE
Sign Originsi Only ,
DATE
CLAIMANT ~
SIGN HERE
11,
8. PAYEE (Sig1l81U1fJ)
APf'ROVING~
OfFICIAL
SlGNHERE
CASH PAYMENT RECEIPT
b. DATE REcEIVED
"
c. AMOUNT
9. This claim is certified correct and proper for payment
Sign Original Only
AUTHORIZED ~
CERTIFYING
OFFICER
SlGNHERE
I
DATE
$
12. PAYMENT MADE
BY CHECK NO.
ACCOUNTING CLASSIFICA TION
1164-210
STANDARD PORM aiM (Rey.lI-m
Prescribed by GSA, PPMR(CFR. 41) 101-7
�8. EXPEHDITURES-Continued
DATe
Show ~ codtIln QlI!
fbi:
AMOUNT CLAIM~
C A-Local travel
0 B-Telephone or telegraph, or
D
E c-other Expenses (itsrnlZfJd)
19_
MIlEAGe
RATE
t
(Exp/(Iin ~""In t!pIICific tItIttti1.)
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MILEAGE
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In compliance with the P!:Iwlqt Act of 1974. the following information is provided: Solicitation of the information on IhIs form is auIhorized by 5 U.s-c. Chapter 57 as implemented by the
Federal Travel R&guIatlona(FPMR 101-n. E.O. 11609ofJuly22, 1971. E.O. 110120f March 27.1962, E.Q. 9397 of November 22, 1943. and 26U.S.C. 6011(b)and8109. Theprlmaly
purpose 01 the requested Infonnatlon is to determine payment or reimbursement to eligible indMduals for allowable travel and/« other expenses Inc!.mId under appropriate
admlnislratN9 auIhorization and to record and maintain costs of such r8imbursements to the Government. The Jnfonnatlonwill be used by Feder8I agencyofficel"s andempJoyees who have
a need for the lnformatlonln theperto;manc:eofthelrolllc:lal duties. The information maybe disclosed to appropriate Federal. Slate, local. «foreign agencies,whenrelevanttociYl,erIninaI,
«regulatory IrWes1Igatlona« prosecutions, «when purwantto a requirement by this agency in connecIIoI. with the hiring «firing of an employee. the Issuance of a 8eCIJf'Ity deIInInce, 01
inYestIgationa 01 the performance of oIIIc:IaI duty while In Governmentservice. Ycu Soc:iaI Security Account Number (SSN) is 8OIic:ited under the authority of the Internal RtMnJ8 Code (28
U.s.c. 6011(b) and 8109) and E.O. 9397. November 22, 1943. for use as a taxpayer and/« employee identification number; dIscIoswe is MANDATORY on vouc:IMn cIaImlnsJ
payment 01 reIrnbI.nement which ... « may be. taxable Income. 0iscI0suI'e of you' SSN and other requested information is voIuntaty In all other Instances; howeIIer. faIh.n to povIde
the information (other than SSN) I'8CII*ed to support the claim may result In delay « Io$s of reimbursement.
~'TANDARD FORM 1164 Back (Rnjl-17)
�
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Kendra Brooks - Subject Series
Creator
An entity primarily responsible for making the resource
Domestic Policy Council
Kendra Brooks
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="http://clinton.presidentiallibraries.us/items/show/36031" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/647992" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
The Kendra Brooks Subject Files contain correspondence, reports, articles, memos, and various printed material. Other documents include background information for education events and meetings. The files include material pertaining to charter schools, national testing, SAT preparation, school safety, school modernization/construction, affirmative action, Blue Ribbon Schools, class–size reduction, teacher quality, Limited English Proficiency (LEP), the White House Initiative on Education Excellence for Hispanic Americans, Tribal Colleges and Universities, Historically Black Colleges and Universities (HBCU’s), the Individuals with Disabilities Education Act (IDEA), and Title 1 of the Elementary and Secondary Education Act of 1965.
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Extent
The size or duration of the resource.
157 folders in 16 boxes
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Reimbursement Forms
Creator
An entity primarily responsible for making the resource
Domestic Policy Council
Kendra Brooks
Subject Files
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 16
<a href="http://clintonlibrary.gov/assets/Documents/Finding-Aids/Systematic/KendraBrookssubjectfile.pdf" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/647992" target="_blank">National Archives Catalog Description</a>
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Publisher
An entity responsible for making the resource available
Clinton Presidential Library & Museum
Medium
The material or physical carrier of the resource.
Reproduction-Reference
Date Created
Date of creation of the resource.
1/17/2012
Source
A related resource from which the described resource is derived
647992-reimbursement-forms.pdf
647992