DATA SHEET TO ACCOMPANY CLAIM FOR REIMBURSEMENT FOR DEPENDENTS’ TRAVEL
*(All entries to be made by the claimant in his own handwriting)*
The following data is submitted in substantiation of my claim for reimbursement for travel performed by my dependents:
MEMBER’S FULL NAME
*Delbert Clement Newhouse*
*(First)* *(Middle)* *(Last)*
*177283* *(Service number)*
*CW0-4* *(Rank/rate)*
ADDRESS TO WHICH CHECK IS TO BE MAILED:
_________________________________________________________
WIFE’S NAME:
*Norma Isabel Newhouse*
**\*CHILDREN’S NAMES:**
*Delbert Carroll Newhouse*
*Anne Lisbet Newhouse*
RELATIONSHIP
*Son*
*Daughter*
DATE OF BIRTH
*6/28/38*
*3/14/40*
*\*Step children or adopted children must be classified as such. Dependent parent must be classified and claimed as such.*
“I certify that my dependents were located at (Street address, city, and State) *3581 SE Grant Court, Portland, Oregon* when orders directing detachment from my old permanent station were received and departed that place on (Date) *7/19/56*; and arrived at (Street address, city, and State) *236 Lakewood Rd, Warrington, Florida*, on (Date) *8/2/56*; that such travel was performed at my own expense, and that the travel covered by this claim represents the entire travel of all my dependents which has been or will be made on this change of station except as follows: (Exception, if any)
_________________________________________________________
If orders direct my travel overseas where dependents are not permitted to go, I HEREBY DESIGNATE (Street address, city, and State)
_________________________________________________________
as point to which transportation of dependents is desired.
I certify that my dependents were last transported or reimbursed at Government expense for travel to
*Portland, Oregon*
NOTE.—This data sheet is to be presented to the disbursing officer with the original and three certified copies of travel orders, with all endorsements. The “Voucher for Reimbursement for Expenses Incident to Dependent Travel” (NAV. S. AND A. FORM 912 Rev.) will be signed when completely filled in. This “Data Sheet” or the “Voucher for Reimbursement for Expenses Incident to Dependents Travel” (NAV. S. AND A. FORM 912 Rev.) will not be signed in blank.
“I further certify that all entries made above are in my own handwriting and are true and correct; that I have read this completed data sheet and understand that any misrepresentation or concealment of material fact by me may work a forfeiture of the claim and subject me to trial by court martial or Federal District court and to penalties extending to 5 years imprisonment or $10,000 fine, or both.”
*(Signature of Claimant)*
*Delbert Newhouse*
NAV. S. AND A. FORM 915 (4-53)
U. S. GOVERNMENT PRINTING OFFICE 16—68710-1