Travel Form

U.S. Department of Justice
Washington, D.C. 20530

[This is the basic format for a request to approve reimbursement of official travel by a non-Federal source.  Please insert names and titles as appropriate, and make other changes or additions as necessary.  More information is better than less. ]

M E M O R A N D U M

To:         [Component Head, e.g., AAG, or Associate AG for OASG officials]

From:       [Employee]

Through:    [DDAEO, Title]
[Office]

Subject:    Approval of Travel Reimbursement

I am requesting your approval for acceptance by the Justice Department of payment of expenses for travel to attend a meeting or similar function related to my official duties.  31 USC 1353, 41 CFR Part 304-1 et seq.  The following information is supplied in support of my request:

1.    The name and sponsor of the event:

2.    The location of the event:

3.    The date(s) of the event:

3a.   The dates I would attend:

4.    The travel dates:

5.    Description of the event including, generally, the other attendees: 

6.    My position:

7.    The name of any organization other than the sponsor offering to pay expenses:

8.    Description and estimated cost of all benefits to be provided (i.e., airfare, lodging, meals, conference fee, ground transportation, etc.  PLEASE specify the class of airfare or train, e.g., coach, business class, etc.):

9.    Type of benefits to be paid in kind (e.g., meals provided during the event, hotel paid directly by non-Federal source):

10.   Type of benefits to be paid by a check made out to the Justice Department:

11.   I am _____  am not _____  working on any matter pending before the Department that would affect the interests of the organization paying my expenses. 

[If there are matters pending, please describe]

12.   Description of any other official business (other than attendance at the event described above) that will be conducted during this trip:

13.   I have ____ have not _____  requested leave in connection with this trip.  If yes, please note dates.

After conducting a conflict of interest analysis, I recommend that the request to accept travel expenses be approved.

 

DATE: __________________________          ___________________________  
[DDAEO, Title]
[Office]

 

APPROVED: __________________________________

DISAPPROVED: _______________________________

DATE: ___________________________         ____________________________
[Component Head/Designee]

AFTER RECEIVING PAYMENT FOR YOUR TRAVEL EXPENSES, PLEASE PROVIDE THE FOLLOWING INFORMATION AND RETURN A COPY OF THE ENTIRE FORM TO YOUR ETHICS OFFICIAL.  (YOU SHOULD NOW REPORT EXACT AMOUNTS ALTHOUGH YOU MAY PROVIDE THE APPROXIMATE COST OF MEALS IF THE EXACT COST IS NOT EASILY AVAILABLE.)

 

TYPE OF BENEFIT RECEIVED

 

COST

 

ACCEPTED IN KIND OR BY CHECK PAYABLE TO DOJ