Ombudsman documents 2. Form 1: Claim for the reimbursement of costs and rewards I, _ ______________________________ by profession_____________________________ residing at_ _______________________ tax number_______________________________ transaction account number ___________________-_______________________________ at (bank)���������������������������������������������������������������� cooperated in monitoring ����������������������������������������������������������������������� ����������������������������������������������������������������������� on _____________________from___________________ to____________________ hours. Please acknowledge and pay: 1. SYMBOLIC PAYMENT number of hours level of reward for each hour or part total EUR 2. PAYMENT FOR PRODUCING REPORT ON MONITORING PERFORMED 3. REIMBURSEMENT OF COSTS a) travelling expenses by public transport for journey from / to b) Kilometer rate for the journey from/ to total km price total EUR per 1 km c) costs for food and accommodation (daily rate) level of daily rate level of costs of accommodation total EUR total EUR d) compensation of pay, lost earnings total EUR In__________________________________, date_________________________________ signature Enclosures: - confirmation of monitoring carried out and report produced - invoices National Preventive Mechanism in the Republic of Slovenia under the Optional Protocol to the UN Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment 133