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1 Attach lodging receipt s as supporting document s. I PATIENT S NAME Type or Print Name certify that itemized amounts are actual and necessary expenses incurred by me in performance of official travel for which I have not been reimbursed. SIGNATURE PATIENT S SIGNATURE WITH DATE DD FORM 1351-3 SEP 1997 PREVIOUS EDITION MAY BE USED UNTIL SUPPLY IS EXHAUSTED. STATEMENT OF ACTUAL EXPENSES SPECIALTY CARE REIMBURSABLE EXPENSES JTR par. C4601 and JFTR par. U4205 DATE LODGING Note 1 MEALS Note 2 BREAKFAST LUNCH DINNER MAR 3 16. 00 MAR 4 16. 50 MAR 5 15. 00 E L MP A X T N IE P LOCAL TRANSPORTATION Note 3 LAUNDRY PRESSING CLEANING G I EL H W OTHER Note 4 M V TR NOTES 4 a Fees and tips to hotel employees Uniformed Services indicate only those fees and tips paid to porters 2 Cost of each meal and tip less the cost of alcoholic and baggage carriers at places of lodging. Fees and tips at common beverages. carrier terminals are separately reimbursable. c Communications charges for lodging reservations d Expenses other than those shown on lodging receipts related to 3 Cost of local transportation and tips for travel between places lodging of lodging or duty points and places where meals are taken not e Expenses for personal laundry and cleaning of clothing. otherwise reimbursable JTR par. C2402 and JFTR par. U3510. See JFTR and JTR Appendix A under definition of per diem for listing of other incidental expenses. STATEMENT OF ACTUAL EXPENSES SPECIALTY CARE REIMBURSABLE EXPENSES JTR par. C4601 and JFTR par. U4205 DATE LODGING Note 1 MEALS Note 2 BREAKFAST LUNCH DINNER MAR 3 16. 00 MAR 4 16. 50 MAR 5 15. 00 E L MP A X T N IE P LOCAL TRANSPORTATION Note 3 LAUNDRY PRESSING CLEANING G I EL H W OTHER Note 4 M V TR NOTES 4 a Fees and tips to hotel employees Uniformed Services indicate only those fees and tips paid to porters 2 Cost of each meal and tip less the cost of alcoholic and baggage carriers at places of lodging. 00 MAR 4 16. 50 MAR 5 15. 00 E L MP A X T N IE P LOCAL TRANSPORTATION Note 3 LAUNDRY PRESSING CLEANING G I EL H W OTHER Note 4 M V TR NOTES 4 a Fees and tips to hotel employees Uniformed Services indicate only those fees and tips paid to porters 2 Cost of each meal and tip less the cost of alcoholic and baggage carriers at places of lodging. Fees and tips at common beverages. carrier terminals are separately reimbursable. c Communications charges for lodging reservations d Expenses other than those shown on lodging receipts related to 3 Cost of local transportation and tips for travel between places lodging of lodging or duty points and places where meals are taken not e Expenses for personal laundry and cleaning of clothing. Fees and tips at common beverages. carrier terminals are separately reimbursable. c Communications charges for lodging reservations d Expenses other than those shown on lodging receipts related to 3 Cost of local transportation and tips for travel between places lodging of lodging or duty points and places where meals are taken not e Expenses for personal laundry and cleaning of clothing. otherwise reimbursable JTR par. C2402 and JFTR par. U3510. See JFTR and JTR Appendix A under definition of per diem for listing of other incidental expenses.

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