EFTA00038871.pdf

FD-794
Version 2.0
Revised 03/11/2021
(Blank form is Unclassified//FOUO, but may be classified when filled in)
FEDERAL BUREAU OF INVESTIGATION
PAYMENT REQUEST
The collection of information on this form is authorized by 5 U.S.C. 301 (FBI authorized to create and retain agency records) and 28 U.S.C. 530C(b)(4) (FBI authorized to use appropriated funds for conduct of its authorized activities). Your Social Security Number is solicited as authorized by E.O. 9397 (Nov. 30, 1943), as amended by E.O. 13478 (Nov. 18, 2008). The information sought will be used by the FBI to process your request for an advance payment of funds or request for reimbursement for authorized commercial or source-related expenses. Disclosure of the requested information is mandatory; failure to provide the requested information will delay the processing of your request and may result in its denial. This information is maintained in the FBI Central Records System, Justice/FBI-002, a description of which can be found at https://go.fbinet.fbi/DO/OGC/LTB/PCLU/PrivacyCivil%20Liberties%20Library/Forms/FBI002.aspx. This information may be disclosed in accordance with the routine uses referenced in this notice.

Cost Code*:
3540
Forfeiture or Drug Related*?
Yes No [Selected: No]
Overall Classification of Form*:
Unclassified

Program/Subprogram* (if not listed, type the 4-5 digital code):
(RIRI) Violent Crimes Against Children, Violent Crimes Against Children
Need help? Use the ENIGMA tool online to confirm correct P/SP by case classification.

INFORMATION ABOUT THE REQUESTING EMPLOYEE
Official Bureau Name*: (Last, First, Middle Initial)
[Redacted]
UEID*:
[Redacted] W [Redacted]
Date of Request*:
10/07/21

Division:
New York
Section/RA:
NYO HQ City
Unit/Squad:
C-20

Telephone Number: (include area code)
[Redacted]
Case Number*:
50D-NY-3027571

Was/will the expense be paid by an alternate employee?
Yes No [Selected: No]

Is this a one time non-symbol source payment*?
Yes No [Selected: No]

If an expense was already incurred, was it paid with personal funds?
If yes, please select your preferred method of reimbursement:
Yes [Selected] No

Justification*:
This request is for the reimbursement of expenses incurred by the case team through the
purchase of meals for a trial witnesses on 06/23/21.

To be completed by FINANCE OFFICE ONLY.
Fund: Organization Level 2: Program: Sub Program: SOC: Sub SOC: Description*: Amount*:
Investigative Expense
Total Request:
Add New Row Remove Row
To be completed by FINANCE OFFICE ONLY.
BBFY: EBFY: Project: User Dimension 4: User Dimension 5:

FD-794
(Blank form is Unclassified//FOUO, but may be classified when filled in)
Page of
EFTA00038871

FD-794
Version 2.0
Revised 03/11/2021
(Blank form is Unclassified//FOUO, but may be classified when filled in)
FEDERAL BUREAU OF INVESTIGATION
PAYMENT REQUEST
APPROVAL

HQ Only
Requestor Supervisor:
Next Level Supervisor:
Signature / Date

Field Only
Supervisor Initials:
SAC/ASAC/AO/SAS:
Digitally Approved via Sentinel
Procurement Authority:

FINANCE OFFICE ONLY
SETTLEMENT OF ADVANCE
Creator
FOS Approver
Document Number:
Commitment:
Obligation:
Advance:
Expense:
Cash Receipt:
Cash Receipt -
OTCnet (CRO):
OTCnet Deposit
Ticket #:
Date: Initials:
Date: Initials:

FD-794
(Blank form is Unclassified//FOUO, but may be classified when filled in)
Page of
EFTA00038872