STATEMENT IN LIEU OF

ACCEPTABLE LODGING RECEIPT

I certify that the required receipt for lodging to support this claim was

Destroyed/ lost/ or the only receipt that I was given. (Circle one)

The following information, constructed to the best of my knowledge, is

furnished in lieu of the proper receipt required to process my claim.

DATES OF LODGING From: ___________ To: ______________

I stayed ____ nights, at a cost of $_________ per night, plus taxes of

$_________. I paid a total amount of $_________ for room charges.

Traveler’s Signature: _____________________________________

SSAN _____-____-_____

DATE _______________

If the accommodations were shared with another person or with family members, only

the traveler’s share of the cost will be reimbursed.

Do not include expenses for food, bar, or telephone in the lodging receipt.