STATEMENT IN LIEU OF LOST RECEIPT(S)
Name: __________________________ Grade/Rank ____________
Date: ____________ T/O# _________
NGIS/NAVY LODGE/COMMERCIAL LODGING
Name: ____________________
Address: ____________________
Rate (Daily) (Single): ____________________
Total Amount Paid: ____________________
Period: From:______To:______
COMMERCIAL TRANSPORTATION
Commercial Transportation was used from ___________ to _________
Date: _____________
Name of the Company _________________ Amount Paid: ___________
OTHER
Type of Expense: ______________________________
Name and Address of Vendor: ______________________________
Total Amount Paid: _________
STATEMENT AS TO WHY RECEIPT(S) WAS/WERE NOT FURNISHED:
_____________________________________________________________________________
The penalty for willfully making a false claim is: A maximum fine of $10,000.00 or maximum
imprisonment of 5 years or both. (U.S. Code Title 18 Section 287) The statements on this form
are true and complete. If the expense for which this certificate is being used is for a rental
vehicle, I further certify the vehicle in question did not exceed the size/make/model authorized
in my orders, was not rented for any non-duty periods nor do the costs include fees for optional
personal injury or collision damage waiver insurance (CONUS rentals only).
PRIVACY ACT STATEMENT: The authority to request this information is contained in 5 USC 301
Department Regulations. This information will be used to process your request for travel claim
liquidation. Completion of the form is mandatory; failure to provide required information may
result in delay in response to or disapproval of your request.
_________________________________________
(Signature) (Date)
