EFTA00185233

U.S. Department of Justice

Authorization for Reimbursement of Unusual Expenses of Fact Witnesses

# Request for Unusual Expense(s) of Fact Witness (For United States Attorney's Office Use Only)

Control #

1. Case Name
   Operation Leap Year
2. Court Docket Number
3. Requesting ALUSA
4. Location of Court Proceeding West Palm Beach
5. Contact Person
6. Contact Person Number

7. Witness Name & Address, Phone #, SSN
8. Vendor Name & Address, Phone #, TIN/SSN

9. Payment to be made to:
10. Receipt/Invoice is:

11. Type of Unusual Expense:
   □ Medically Necessary Item
   (Attached Supporting Statement)
   ☑ Dependent Care
   □ Excess Lodging/Per Diem
   □ Travel & Transportation
   □ Pretrial Conference Waiver
   □ Other

12. Explanation:
   The witness has a small child and would not had no one who could watch the child while she justified.

13. Start Date of Service (MO/DA/YR)
    2/6/07

14. End Date of Service (MO/DA/YR)
    2/6/07

15. Amount

16. Justification:

17. I hereby certify that the expenses and services listed on this document are appropriate and are within the Federal laws and regulations. I fully understand that I can be held personally liable or be subject to disciplinary action for improperly using government funds or services that exceed delegated authority or that violate Federal laws or regulations.

<table border="1"><tr><td colspan="2">Signature of Requesting AUSA</td><td colspan="2">Date</td></tr><tr><td>18. Name &amp; Title of Approving Official</td><td>19. Date (MO/DA/YR)</td><td colspan="2">20. Signature of Approving Official</td></tr><tr><td colspan="3"></td><td>UFWE Form</td></tr></table>