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FD-794 Version 1.7 FEDERAL BUREAU OF INVESTIGATION Revised PAYMENT REQUEST 01-10-2017 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.5.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.0. 9397 (Nov. 30, 1943), as amended by E.0. 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 foundatwwwkwwx.This infomaton maye disclosed in accordance with the routine uses referenced in this notice Cost Code Forfeiture or Drug Related ? Proqram/Subprogram*(if subprogram not listed, type 4 digit code): M Yes No de thncimcomy cess Information about the requestIng EmpLOyee b6 -1 Official Bureau Name: (Last, First, Middle Initial). UEID: Date of Request: b7C -1 b7E-1,2,3,5 Division: Section/RA Unit/Squad: Telenhone Number: (incude area code) Case Number: INFORMATION ABOUT THE REQUESTED PAYEE Alternate Name: (Last,First,MI Division/Section/Unit: VEID: `b7C -1 EC Serial Reference Number: b7E -2,5,19 Is this a one time non-symbol source payment YesNo Justification: b7E -5,19 Org. Sub Level 2: Program Program: Fund: sOC: Sub Soc: Description*: Amount: Total Request: To be completed by Finance Office only:. BBFY: EBFY: Pa rtition: Project: User Dimension 4: User Dimension 5: FBI 22-cv-2152(FBH)-9455 FD-794 Page 1 of 2 FEDERAL BUREAU OF INVESTIGATION