EMPLOYEE VACATION DECLARATION

Contractor

Cn

Route No.

1053b

The following employees are assigned as drivers of the above numbered route and have the length of employment service as shown below: Name S/S #

\Mth You

Date of Service

Any Predecessor*

O.bllut

ldentify any immediate predecessor by name/address and dates employed.

complete. I further certify that I will promptly notify the Postal Service of any additions or deletions to the information supplied. I further understand that the information furnished is subject to audit.
I certify that to the best of my knowledge the above information is true, accurate and

Date: t'Lq

l"

,rnn"rur.,

CRIMINAL PENALTY FOR PRESENTING FRAUDULENT CLAIM OR MAKING FALSE STATEMENTS

A fine of not more than glO,OOO or imprisonment for not more than 5 years or both. (See 18 U.S.C. 287, 1001)

CIVIL PENALTY FOR PRESENTING FALSE GLAIMS OR STATEMENTS

The claimant shallforfeit and pay to the United States Postal Service up to $5,000 per claim or statement and up to two times the amount paid by the United States Postal Service. (See U.S.C. Secs. 3801-3812) Furthermore, the claimant may be liable to the Unites States for up to $10,000 per claim or statement and up to three times the amount of damages the Government sustains. (See 31 U.S.C. Sec. 3729)

TMS 14I

EMPLOYEE VACATION DECLARATION

contractor

M,sf,t -lr,,ns rorls

,

Route

No. IAOJI

The following employees are assigned as drivers of the above numbered route and have the length of employment service as shown below:

Name
&

S/S #

V/ith

*,2

581 q0- 3t35

You a br lw14

Date of Service

Any Predecessor*

ldentify any immediate predecessor by name/address and dates employed.

I certify that to the best of my knowledge the above information is true, accurate and complete. I further certify that I will promptly notifo the Postal Service of any additions or deletions to the information supplied. I further understand that the information furnished is subject to audit.

Date: ll

Signature:

GRIMINAL PENALW FOR PRESENTING FRAUDULENT CLAIM OR MAKING FALSE STATEMENTS A fine of not more than $10,000 or imprisonment for not more than 5 years or both. (See 18 U.S.C. 287, 1OO1) CIVIL PENALTY FOR PRESENTING FALSE CLAIMS OR STATEMENTS
The claimant shallforfeit and pay to the United States Postal Service up to $5,000 per claim or statement and up to two times the amount paid by the United States Postal Service. (See U.S.C. Secs. 3801-3812) Furthermore, the claimant may be liable to the Unites States for up to $10,000 per claim or statement and up to three times the amount of damages the Government sustains. (See 31 U.S.C. Sec. 3729)

TMS 14I

EMPLOYEE VACATION DECLARATION

Contractoq

M,t{

Route

No. IASLb

The following employees are assigned as drivers of the above numbered route and have the length of employment service as shown below: Name S/S #

\Mth You

Date of Service

Any Predecessor* ,i.r'r

rtq.lbEoba

r?/or

ilzcro

u (Jo,n1rc,.fur

ldentify any immediate predecessor by name/address and dates employed'

complete. I further certify I further that I will prompfly notify the postal Service of any additions or deletions to the information supplied. understand that the information furnished is subject to audit.
I certify that to the best of my knowledge the above information is true, accurate and

Date:

CRIMINAL PENALTY FOR PRESENTING FR,AUDULENT CLATM OR MAKING FALSE STATEiIIENTS (See 18 U'S.C' 287, 1001) A fine of not more than $1O,0OO or imprisonment for not more than 5 years or both. CIVIL PENALTY FOR PRESENTING FALSE CLAIMS OR STATEMENTS
per claim or statement and up The claimant shallforfeit and pay to the United states Postal service up to $5,000 (See U.S.C. Secs. 3801-3812) to two times the amount paid bvine United States Postal Service. per claim or statement and up to Furthermore, the claimant may be liable to the Unites States for up to $10,00_0 Sec' 3729) three times the amount of damages the Government sustains. (See 31 U.S.C.

TMS I4I