Settlement request of travel expenses

through GIZ Office (local & international travel)

Given name, family name Personnel number (GIZ only) Processing number (12-digits)
..

I am: AMA NMA EH CIM Counterpart Consultant other (external traveler funded by GIZ)
Purpose of journey :
     

Costs for which evidence has been provided

Year: 2019
Start End Travel route Lumpsum Travel by
Date time time from – to Per-diem Overnight overnight
from – to accomo- private car
allowance dation
accomo-
dation (KM)

Total

The following items were provided free of charge by GIZ or third parties acting on its behalf:

Accommodation Breakfast Lunch Dinner

On / from – to On / from – to On / from – to On / from - to
           
           
           

Accommodation remark: lump sum payment against invoices (hotel bill)

Advance payment received Amount: No advance payment received

Advance currency MZN USD Ticket by GIZ Project Vehicle

Private on/ from-to (date _

&time):

Total Value for reimbursement:

Cost offsetting to other projects :

Processing number Purpose of Journey % Total Amount

Total

Payment Options: Cash Cheque Bank transfer

Bank details:
Account name:
Bank name:
Account number:

I confirm, the information provided above is complete and correct.

Date, signature

GIZ Form 54_3 (Settlement Request Form – Mozambique 08-2019)

 Settlement request of travel expenses
through GIZ Office (local & international travel)

     
Traveler Superior or Officer responsible GIZ Office

GIZ Form 54_3 (Settlement Request Form – Mozambique 08-2019)