Perjalanan d2p Surabaya

THE WORLDBANK GROUP
STATEMENT OF EXPENSES FOR FIELD OFFICE USE

Name (Last, First, M.I)
ACHMAD AFFANDI NASUTION
Travel
Operational
Staf
Consultant
Staff or Consultant No.

348181
Resettlement
Relocation
FOR HQ ACCOUNTING USE ONLY
Applicant
EDI
Other
Travel Request No.

Official Station
1000364101
2-Feb
3-Feb
To
Single
Dept. :
Washington, DC
Period of Travel
Married
Year
Year
Field Office (Please enter field office name)
Payment Address/ Bank Account
2015
2015
A. ADVANCES
Include amount received for excess baggage and
Corporate Charge Plate Holder ?
value of misscellaneous charge orders (MCO).
Room No.
Division
Product Id.
Currency
1 Funds received from :
- Travel Vendor - HQ
- Field Office
- ACTAE
- Other
US $
No
Ext.
No.
MGR.
SOF
SOF Acct.
B. TRANSPORTATION
0.00
0.00
0.00
0.00
3 Funds returned to :
- Field Office
- Other
4 Net. Adv. (1 less 2 & 3)
5 Exchange rates used :
6 Net Advances US$ Equivalent
0.00
0.00
0.00
0.00
0.00
0.00
0.00
E SUMMARY
Total Expenses, US$ Equivalent
(from Section G)
10,670,300.00
Total Net Advances, US$ Equivalent

(from Section A)
0.00
*Check enclosed
Yes
US $
US $
Did Field Office provide any ticket(s) ?
Yes
No
Any part of ticket(s) unused and returned ?
Yes
No
Any part of ticket(s) downgraded ?
Yes
No
Advance for excess baggage provided ?
Yes
No
Any MCO unused ?
Yes
No
C. SPOUSE TRAVEL POINTS

Did Spouse travel ?
Yes
No
D. RELOCATION OR RESETTLEMENT TRAVEL

This submission includes expenses for the following members of my family
Name
Relationship
0.00
Bank *
Traveler
Thomas Cook
0.00
0.00
Total Net Advances, US$ Equivalent
US$Balance
Balance
US$
duedue
AmEx
Other :
2 Funds given to : (attached form 2093)

Name
10,670,300.00
No
If No, Field Office Name

Check No.
I certify that tickets provided to me by Bank Group were used as issued, or if transportation,
routing, class of travel or type of fare, was rearranged by me, that an explanation is attached
and that I did not receive a refund in connection with any such changes. I have not received
and will not claim reimbursement from any other source
Signature of Traveler
Yes
Are additional expenses expected to

Yes
submitted for other members of your family
Name
Relationship
No
Submission
Date
Date
4-Feb-15
For Operational Travel Only

I confirm that the itinerary was undertaken for the purpose of official business, except where noted otherwise, and that the expenses and Representation
claims are appropriate and that the explanation of nay policy deviation is accepted
Staff Member's Dept. Signature of Approval
Date
Signature of Sharing Dept.'s Approval
Date
4-Feb-15
Send completed form to Administrative Expense Division, ACTTR. Include copies of : Approved travel request, travel order and itinerary, hotel bills
transportation ticket jackets and all other vouchers and receipt (I.e. currency exchange receipts)
RRP-96
F. EXPENSES
List expenses by city currency. Use separate column for each currency, if more than six columns check box 0 and attach additional
form that includes only your name and travel request number on the front page. Use abbreviation for country, city and currency. For city
abbreviation use first five letters of city name
Country
City
Currency
Arrival
Mo. Day Hour a/
Departure Mo. Day Hour a/
PURPOSE OF STAY CODE b/
Hotel Code
Hotel Name
Room Rate
Hotel and Tax
Meals, tips and valet
in, out and within c/
Transportation d/
Phone, Cable and Fax d/
Representation d/
Miscellaneous d/
Per Diem
Exchange Rate
Indonesia
Jakarta
IDR
02-02-15 :: 04.45
180,000.00
Indonesia
Surabaya
IDR
02-02-15::06.30
02-03-15::15.00
Operational
Indonesia
Jakarta
IDR
02-03-15::16.25
1,276,800.00
75,000.00
540,000.00
120,000.00
1.00
8,478,500.00
0.00
1.00
TOTAL CURRENCY
180,000.00
10,370,300.00
120,000.00
0.00
0.00
0.00
US$ EQUIVALENT
180,000.00
10,370,300.00
120,000.00
0.00
0.00
0.00
1.00
G. EXPLANATION FOR OTHER EXPENSES LISTED IN SECTION F. ABOVE

Expenses Item
In/Out
MTV
Transportation
Miscellaneous
Taxi (home - airport, v v); airport tax

=(4/5 x $73 x 12000) +(4/5 x $60 x 12000)
Day 1 : Airport-Hotel, IDR 150,000
Day 1 : Hotel-BPKP, IDR 110,000
Day 1 : BPKP-Hotel, IDR 130,000
Day 2: Hotel - BPKP, IDR 110,000
Day 2: BPKP-Airport, IDR 40,000
Lunch box and coffee break for meeting of LGDP verification and safeguard workshop for BPKP verificator,
Day 1 with 60 participants; and, Day 2 with 35 participants.
H. EXPLANATION FOR ENROUTE CHANGE IN CLASS OF TRAVEL

Were there any enroute itinerary changes involving Class or Date of Travel or Stopover City ?
If Yes, were those changes within the policy
Yes
No
Yes
No
a. In all cases, please provide in the comments section below the Carrier, Flight No., From/To Cities, Departure/Arrival Dates
and Class of Travel for any enroute changes.
b. If Changes were not within policy, please also provide an explanation in the Remarks Section below.
Carrier
REMARKS
Flight No
From City
To City
Depart. Date
Arrival Date
I. LEAVE DURING OPERATIONAL TRAVEL

Was leave taken during this travel period ?
If Yes, please enter :
Annual/Home
Sick
a/ Fill in military time nearest hour

b/ Valid purpose codes: P-Annual Leave, including weekends and holidays when on personal leave status for which no
expenses are claimed; C-Connection; OP-Operational; S-Stop Over.
c/ In, Out and Within is transportation, airport tax and baggage handling
d/ Expenses under these categories require explanation in section H
Yes
No
F. EXPENSES
Country
City
Currency
Arrival
Mo. Day Hour a/
Hotel Code
Hotel Name
Room Rate
Hotel and Tax
Transportation d/
Representation d/
Miscellaneous d/
Per Diem
Exchange Rate
TOTAL CURRENCY
0.00
0.00
0.00
0.00
0.00
0.00
US$ EQUIVALENT
0.00
0.00
0.00
0.00
0.00
0.00

Expenses Item

Carrier
REMARKS
Flight No
From City
To City
Depart. Date
Arrival Date

Annual/Home
Sick

F. EXPENSES
Country
City
Currency
Arrival
Mo. Day Hour a/
Hotel Code
Hotel Name
Room Rate
Hotel and Tax
Transportation d/
Representation d/
Miscellaneous d/
Per Diem
Exchange Rate
TOTAL CURRENCY
0.00
0.00
0.00
0.00
0.00
0.00
US$ EQUIVALENT
0.00
0.00
0.00
0.00
0.00
0.00

Expenses Item

Carrier
REMARKS
Flight No
From City
To City
Depart. Date
Arrival Date

Annual/Home
Sick

F. EXPENSES
Country
City
Currency
Arrival
Mo. Day Hour a/
Hotel Code
Hotel Name
Room Rate
Hotel and Tax
Transportation d/
Representation d/
Miscellaneous d/
Per Diem
Exchange Rate
TOTAL CURRENCY
0.00
0.00
0.00
0.00
0.00
0.00
US$ EQUIVALENT
0.00
0.00
0.00
0.00
0.00
0.00

Expenses Item

Carrier
REMARKS
Flight No
From City
To City
Depart. Date
Arrival Date

Annual/Home
Sick

Temp Sheet
F. EXPENSES
Country
City
Currency
Arrival
Mo. Day Hour a/
Hotel Code
Hotel Name
Room Rate
Hotel and Tax
Transportation d/
Representation d/
Miscellaneous d/
Per Diem
Exchange Rate
TOTAL CURRENCY
0.00
0.00
0.00
0.00
US$ EQUIVALENT
0.00
0.00
0.00
0.00

Expenses Item

a. In all cases, please provide in the comments section below the Carrier, Flight No., From/To Cities, Departure/Arrival Dat
Carrier
Flight No
From City
Page 6
To City
Depart. Date
Temp Sheet
REMARKS
I. LEAVE DURING OPERATION

Was leave taken during this trav
Annual/Home
Sick

Page 7
Temp Sheet
0.00
0.00
0.00
0.00
ies, Departure/Arrival Dates
Arrival Date
Page 8
Temp Sheet
VE DURING OPERATIONAL TRAVEL

ave taken during this travel period ?
please enter :
status for which no
Page 9

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THE WORLDBANK GROUP

STATEMENT OF EXPENSES FOR FIELD OFFICE USE

Staff or Consultant No.

FOR HQ ACCOUNTING USE ONLY

Travel Request No.

Field Office (Please enter field office name)

Payment Address/ Bank Account

Corporate Charge Plate Holder ?

value of misscellaneous charge orders (MCO).

Total Net Advances, US$ Equivalent

Did Field Office provide any ticket(s) ?

Any part of ticket(s) unused and returned ?

Any part of ticket(s) downgraded ?

Advance for excess baggage provided ?

Any MCO unused ?

C. SPOUSE TRAVEL POINTS

D. RELOCATION OR RESETTLEMENT TRAVEL

Total Net Advances, US$ Equivalent

2 Funds given to : (attached form 2093)

If No, Field Office Name

Are additional expenses expected to

For Operational Travel Only

G. EXPLANATION FOR OTHER EXPENSES LISTED IN SECTION F. ABOVE

Taxi (home - airport, v v); airport tax

H. EXPLANATION FOR ENROUTE CHANGE IN CLASS OF TRAVEL

I. LEAVE DURING OPERATIONAL TRAVEL

a/ Fill in military time nearest hour

G. EXPLANATION FOR OTHER EXPENSES LISTED IN SECTION F. ABOVE

H. EXPLANATION FOR ENROUTE CHANGE IN CLASS OF TRAVEL

I. LEAVE DURING OPERATIONAL TRAVEL

a/ Fill in military time nearest hour

G. EXPLANATION FOR OTHER EXPENSES LISTED IN SECTION F. ABOVE

H. EXPLANATION FOR ENROUTE CHANGE IN CLASS OF TRAVEL

I. LEAVE DURING OPERATIONAL TRAVEL

a/ Fill in military time nearest hour

G. EXPLANATION FOR OTHER EXPENSES LISTED IN SECTION F. ABOVE

H. EXPLANATION FOR ENROUTE CHANGE IN CLASS OF TRAVEL

I. LEAVE DURING OPERATIONAL TRAVEL

a/ Fill in military time nearest hour

G. EXPLANATION FOR OTHER EXPENSES LISTED IN SECTION F. ABOVE

H. EXPLANATION FOR ENROUTE CHANGE IN CLASS OF TRAVEL

I. LEAVE DURING OPERATION

a/ Fill in military time nearest hour

ies, Departure/Arrival Dates

VE DURING OPERATIONAL TRAVEL

status for which no

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