(WHO PAID FOR THE TRJP):

I (Spacif?

SIGNATURE OF EMPLOYEE:  Q.

3E Original  Amendment

 HOu-se of Representatives 
 TRA VEL DISCLOSURE FORJIJ

 form is for disclosing the receipt Of travel exPenses from private sources for meetings, speaking engagements,

fact-?nding trips or similar events in connection with of?cial duties. You need not disclose government-funded or
political travel on this form, or travel that is unrelated to of?cial duties. This form does not eliminate the need to
report all privately funded travel on the annual Financial Disclosure Statements of those persons required to ?le
them. 'In aCcordance with clause 5 of House Rule 26, complete this form and ?le it with the Clerk of the House of
Representatives, B-106 Cannon 'House Of?ce Building, within 30 days after travel is completed; The Clerk is to
make these forms publicly available as soon as possible after they are ?led. Obtain the dollar amounts?om the
c: -

 

 

 

 

 

 

sponsor; if exact dollar amounts are unavailable, provide a good faith estimate.  I: i   
 OF EMPLOYEE (PRINT OR TYPE): Bill Cooper  
NAME OF ACCOMPANYING FAMILY MEMBER (if any): n/a    
RELATIONSHIP TO EMPLOYEE (check one): I Spouse Dchild  -  - 
OF TRAVEL: October .17, 19, 2004 . 
DATES AT PERSONAL EXPENSE: n15 1  
ITINERARY: - See attached Ok? 
. Interstate Oil  Gas Compact Comrnigsm' .-

 

TURPOSE OF TRIP: Energy policiy

TOTAL TRANSPORTATION EXPENSES:
For employee: 617.90

or accompanying spouse or child:

TOTAL LODGING EXPENSES:
For employeei 262.70
For accompanying spouse or child: 

MEAL EXPENSES:
For employee: 84.94

'For accompanying spouse or child:

employee: n/a

iFor' accompanying Spouse or child:

DATE 11/15/04

 

4 I authorized this travel in advance. have determined that all Of the expenses listed above were necessary and that
the travel was in connection with the employee's Of?cial duties and would not create the appearance that he/she is

.-using public Of?ce for private gain.

 

I  0F (Print or Type):

SIGNATURE OF SUPERVISING 

 

 

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