Sample Law Firm Travel Voucher

Section 1 - Traveler Information
Name of Traveler (Last, First, MI) - John Doe
Home Office - Atlanta, GA
Federal Tax Number - 555111322
Invoice Number - 2222
Residence (Include City, State, and ZIP Code) - 123 Street, Altanta, GA 34567
Law Firm Name - Doe & Doe Law Firm
Matter Number - 930000000

 Date

Nature of Expense
(Departure/Arrival are Required for Per Diem Payment)

Amount
Claimed
Mileage

Amount
Claimed
Per Diem

Amount
Claimed
Lodging
Amount
Claimed
Air Fare
Amount
Claimed
Car Rental
Amount
Claimed
Other
  Purpose of Travel - REO Meeting - Tampa, FL            
 1-02-05 Leave Office 10:30am            
  Train from office to airport           1.00
  Taxi to temporary assignment           7:00
  Arrive temporary assignment 1:15pm   22.50 57:00      
  Taxi from temporary assignment to hotel            
               
1-3-05 Leave temporary assignment 7:35am            
  Taxi from hotel to AP           7:00
  Train, AP to office           1:00
  Arrive office 10:30 am   15:00        
  Air fare RT ATL/PA/ATL       200.00    
Totals     37.50 57.00 200.00   28.00

Note: If additional space is needed, complete and attach from FDIC 5210/12A, Law Firm Travel Voucher (Continuation Sheet)
Section 2 - Certification
I certify that I have examined this travel voucher and to the best of my knowledge and belief all costs claimed are allowable in accordance with FDIC travel regulations. Costs claimed here have not been previously billed to FDIC unless identified as a resubmission.
Name/Title of FDIC Oversight Attorney
Signature
Date
FDIC Form number 5210/12 (4-04)