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 29/5/14

Name

Agernesh Ayenew

Phone Number

0910542208

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: 29/5/14____

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
DEP: Gonder
ARR: Metema
DEP: Metema
ARR: Gondar
DEP: Gondar
ARR: Takusa
DEP: Takusa
ARR: Gondar
DEP: Gondar
ARR: Tach Armachiho

DATE
dd

mm

yy

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

11

14

11
15

5
5

14
14

5
5
5

14
14
14

Road

15
16
16

5
5

14
14

Road

19
19

5
5

14
14

Road

20
20

5
5

14
14

Road

28
28

Road
Road

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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