Free OBD 0003 REV 1 - New Hampshire

U.S. Department of Justice Washington, D.C. 20530

Fact Witness Voucher

THIS IS A 4-PART FORM. FILL OUT FORM AND PRINT 4 COPIES. SIGN AS NEEDED AND ROUTE AS SPECIFIED BELOW. Page 1 of 3
Check One I I I Witness Name: Social Security Number: Address: City: State: Zip: (was) (was) (Did) (was not) a United States citizen at the time of attendance (was not) a Federal Government employee at the time of attendance (did not) receive a cash or check advance. Total advance issued: $ Court Doc. No: Case Name: District: Court Location: GTA Transportation Lodging

From:

Telephone No. (including area code):

(Retention of these fees is considered taxable income and reportable to IRS)

PART I - Attendance Certification (by Government Official)

Object Class

Amounts (Dollars) (To Be completed by US Marshals)

A.

Attendance Fees Deposition Dates Grand Jury/Trial Attendance Date (Including Travel) Pretrial Attendance Dates (Including Travel) Detained Dates - Citizen/Visitor In Custody Detained Dates - Deportable Alien in Custody $40 @ $40 @ $40 @ $40 @ $1 @ days days days days days 1126 1156 1194 1193 1195

Total Fees
B.

0

Attendance Attestation: I attest that the witness named above attended in the case or matter indicated and is entitled to the statutory allowance for attendance and travel. In proceedings before U.S. Magistrate Judges where more than four witnesses were called, the Magistrate also attests that the approval and certificate of the Litigating Trial Office were first obtained.

Signature

Title of Authorized Government Official This form is continued on Page 2

Date

Original - USMS Trial District Office Copy 1 - Paying Office Copy 2 - DOJ Litigating Trial Office Copy 3 - Witness Previous Editions are Obsolete

Form OBD-3 (Revised 4-2005)

U.S. Department of Justice Washington, D.C. 20530

Fact Witness Voucher
Page 2 of 3

PART II - Allowances
C. Travel by Carrier (Receipts required if paid by witness) (DO NOT claim if paid by Government) Check one Train Bus Airpl ane D. Travel by Privately Owned Vehicle: Auto/Truck/Van Motorcycle Airplane Round trip mileage @ $ Per mile Total no. of trips Less advance received $

2191

2192

E. Local Transportation & Other Expenses: (e.g., subway, bus, taxi, tolls, all parking, etc.) (Receipts required for parking and expenses over $25.00) (Gratuities are limited to taxi and shuttle services up to 15%) List (item and amount) 2193 F. Meals and Lodging: x Day(s) = $ 1. Travel days (½ day's M&IE per day) @ $ 2. Days away from home (full day's M&IE per day) @ $ x Day(s) = $ 3. Actual cost of lodging, not to exceed $ @ $ x Day(s) = $ (DO NOT claim if paid by Government) (Receipts are required if paid by witness) Less advance received $ G. Witness Certification: I certify that this voucher is true and correct to the best of my knowledge and belief, and that payment or credit has not been received by me. (If not a citizen, present your Alien Registration Record with this form)

2194

Witness Signature

Date

Alien Registration Record No.

H. Claim Verification: Based upon the above information and receipts furnished by the witness, I verify the above information is true and correct to the best of my knowledge. Net Amount Paid

Signature

Title of Authorized Government Official

Date

PART III - Certification
THIS VOUCHER IS CERTIFIED CORRECT AND PROPER FOR PAYMENT

Signature

Title of Authorized Certifying Officer

Date

PART IV - Disbursement
Accounting Classification Check/Draft No. Voucher No.

(For Finance Office use only)

Signature

Title of Disbursing Officer

Dat e

The Privacy Act Statement and instructions for completion of this form are contained on Page 3 of this form

Submit

Go

Form OBD-3 (Revised 4-2005)

U.S. Department of Justice Washington, D.C. 20530

Fact Witness Voucher
Page 3 of 3

INSTRUCTIONS FOR COMPLETING THIS FORM
To be completed by the witness
1. At the top of the form, check the appropriate word(s) to indicate if:

You were or were not a United States citizen at the time you appeared to testify. If you are not a citizen, you will be required to show proof of your resident or visitor status. You were or were not a federal employee at the time you appeared to testify. The fees and allowances on this form do not apply to federal employees. If you are a federal employee, please request instructions for obtaining reimbursement. You (DID) or (DID NOT) receive a check or cash advance for your expenses in traveling to court. If you received an advance, enter the amount and issuing office here. Indicate and/or verify your name, Social Security Number, address, and telephone number to ensure that they are correct. This will be the address to which any reimbursement to you for fees or allowances will be mailed. Correct any erroneous information and enter any missing information. SOCIAL SECURITY NUMBER/PRIVACY ACT NOTICE: Disclosure of your social security number is mandatory for Federal income tax reporting purposes under the authority of 26 CFR Section 301-6109-1, in order to ensure the accuracy of income computation by the Internal Revenue Service. This information will be used to identify an individual who is compensated by funds of the Department of Justice. Failure to provide this information may result in delay of your compensation, and the Department of Justice will be required to notify the Internal Revenue Service that your number is unknown. This information is being provided on Form 1099 to the Internal Revenue Service. 2. PART II - Allowances

Receipts are required for travel by train, bus or air, ALL PARKING, and other single items over $25.00. If you parked at an airport or have not yet paid your hotel/motel bill or other item requiring a receipt, it will be necessary for you to mail your receipts to the trial office. Your claim for reimbursement cannot be processed until you furnish all receipts for expenses that you are claiming on this Fact Witness Voucher. Please note: EXPENSES ASSOCIATED WITH YOUR TRAVEL BY YOUR PRIVATELY OWNED VEHICLE ARE LIMITED TO NO GREATER THAN THE COST OF COACH AIRFARE.

The remaining portion of Part II will be completed for you by the Federal government employee assigned to assist you, with the exception of the Witness Certification. G. Witness Certification: Verify that all items under Part II are correct. Any changes to Part II must be effected and signed by the Federal government employee assigned to assist you. Sign you full legal name and the date. If you are not a United States citizen, you will be requested to show proof of your resident or visitor status.

Falsification of an item may constitute a forfeiture of claim (28 U.S.C., Section 2514) and may result in a fine of not more than $10,000 or imprisonment of not more than 5 years or both (18 U.S.C. 287). Section B of Part I must be signed by an employee of the office that requested the appearance of the witness. Additionally, Section H of Part II must be signed by an employee of the requesting office attesting to the accuracy and completeness of the expenses claimed by the witness before the form is transmitted to the U.S. Marshals Service for payment. The U.S. Marshals Service will process the Fact Witness Voucher and MAIL payment to you at the address indicated on the first page of this form. If you require funds to return home, you must bring this fact to the attention of the individual assigned to assist you.

INSTRUCTIONS TO COMPLETING OFFICE
Section H of Part II must be signed by an employee of the office who requested the appearance of this witness, before the form is transmitted to the United States Marshals Service. Any revisions to Part II must be initialed by a Federal government employee. Changes made to Part II by the witness will not be honored. All receipts for claims made in Part II must be attached to the Form OBD-3 before it is transmitted to the United States Marshals Service for payment. Distribution of the Form OBD-3 shall be as follows: The ORIGINAL signed, completed form is retained by the U.S. Marshals Service. One COPY of the signed, completed form is provided to the Paying Office; one COPY is provided to the DOJ Litigating Trial Office; and one COPY is provided to the witness.

Form OBD-3 (Revised 4-2005)