UNICEF TRAVEL CLAIM FORM

Completed within 15 days of trip completion - please type or print - ALL CLAIMS MUST BE ACCOMPANIED BY ORIGINAL TA

TA #

ETHA/

Date 25/11/13

Name

Getachew Mekonnen

Phone Number

0911071149

I certify that the following is correct, that travel took place as indicated and to repay any travel allowances to which I am not entitled. I authorize
UNICEF to treat this as the FINAL CLAIM unless otherwise specified below.

Signature of Claimant: ________________________________________

Date: 25/11/13____

TERMINAL ALLOWANCE & OTHER EXPENSES

Electronic payment
number

or

Mail check to bank a/c

Attachment
Number

Date

Description of Expenses

Currency

Amount

ITINERARY CHANGES
Short description of changes including times and name of Approving Manager
TRAVEL
ITINERARY

MODE
OF
TRAVEL
Air, road,
rail,
other

DEP: Bahir Dar

ARR: Gonder

Road

DEP: Gonder
ARR: Dessie

Road

DEP: Dessie
ARR: Debre Birhan

Road

DEP: Debre Birhan

ARR: Debre Markos

Road

DEP: Debre Markos

ARR: Bahir Dar

Road

DATE
dd

mm

yy

11

11

13

11

11

13

13

11

13

13

11

13

17

11

13

17

11

13

21

11

13

21

11

13

23

11

13

23

11

13

Indicate
if UN,
GOVT or
other
entitys
vehicle
was made
available
at DEP
&/or
ARR

Is meals
provided
by
UNICEF
,GOVT
or other
entity

Is Accom.
Covered
by
UNICEF,
GOVT or
other
entity

Notes

This claim is in conformity with the journey as actually authorized. Payment of subsistence and Transit allowances is approved for all official stopovers and necessary
travel time reported by the claimant except as otherwise noted. Additional miscellaneous expenses must be approved by Approving Officer below .

Approving /Certifying Officer Name: ______________________________

Signature: _________________________________ Date __________________

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