MEMBER/OFFICER POST-TRAVEL DISCLOSURE FORM

is form is for disclosing the receipt of travel expenses from a private source for travel taken in connection with a

Member or ocer’s ocial duties. is form does not eliminate the need to report privately-funded travel on the Member

or ocer’s annual Financial Disclosure Statement. In accordance with House Rule 25, clause 5, you must complete this

form and le it with the Clerk of the House,by email at gitravelreports@mail.house.gov, within 15 days aer travel is

completed. Please do not le this form with the Committee on Ethics.

NOTE: Willful or knowing misrepresentations on this form may be subject to criminal prosecution pursuant to 18 U.S.C. § 1001.

1. Name of Traveler: ______________________________________________________________________________

2. a. Name of Accompanying Relative: ____________________________________________________ OR None o

7. Attached to this form are each of the following, signify that each item is attached by checking the corresponding box:

a. o a completed Sponsor Post-Travel Disclosure Form;

c. o page 2 of the completed Traveler Form submitted by the Member or ocer; and

d. o the letter from the Committee on Ethics approving my participation on this trip.

8. a. o I represent that I participated in each of the activities reected in the attached sponsor's agenda.

Signify statement is true by checking the box.

b. If not, explain:

I certify that the information contained in this form is true, complete, and correct to the best of my knowledge. I have

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Original

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Amendment

Vice President Kamala Harrais)

directly to the Committee by each invited House Member, ocer, or employee, together with the completed and signed

trip sponsor form(s) and any attachments. A copy of this form, minus this initial page, will be made available for public

inspection. is form and any attachments may be delivered to the Committee at 1015 Longworth or e-mailed to

travel.requests@mail.house.gov.

Signature: ________________________________________________________________________________________

Name of Signatory (if other than traveler): ______________________________________________________________

Oce Address: ____________________________________________________________________________________

Telephone Number: ________________________________________________________________________________

Email Address of Contact Person: _____________________________________________________________________

 Check this box if the sponsoring entity is a media outlet, the purpose of the trip is to make a media appearance sponsored by that

entity, and these forms are being submitted to the Committee less than 30 days before the trip departure date.

NOTE: You must complete all of the contact information fields above, as Committee staff may need to contact you if additional

1. Name of Traveler: _______________________________________________________________________________

______________________________________________________________________________________________

3. City and State OR Foreign Country of Travel : _________________________________________________________

b. If yes, and you are requesting lodging for two nights, explain why the second night is warranted:

7. Yes  No  Primary Trip Sponsor Form is attached, including agenda, invitee list, and any other attachments

9. Yes  No  Is the traveler aware of any registered federal lobbyists or foreign agents involved planning,

organizing, requesting, or arranging the trip?

Signature of Employing Member ____________________________________________ Date ___________________