ABCDEFGHIJKLMNOPQRSTUVWXYZ
1
County of Santa Clara 2025
2
NON-TRAVEL RELATED MILEAGE REIMBURSEMENT FORM
3
4
Budget Unit/Dept#:
921-6767-Medicine Residency
Auto License #:
5
Name:Period Covered by Claim:
6
7
Assigned Destination Address:
Headquarters (Work Location):
8
751 S. Bascom Ave., San Jose, CA 95128
9
10
DateOrigin & Destination AddressMiles
11
Purpose of TripClaimed
12
Home Address:
13
Assigned Destination Address:
14
Purpose of Trip(s):
15
Number of shifts:
16
(Home to Assigned Destination - Home to SCVMC) x 2= Round Trip
17
Number of Shifts x Round Trip= Total Miles Claimed
18
19
20
21
22
23
24
25
Employee ID NumberTCN/WDN (5)Seq (2)Pay Code
26
92177MITotal Miles Claimed
27
 Employee Certification & Departmental Approval
I hereby certify under penalty of perjury that the above trips were necessary in the performance of my duty. Claim is hereby made for mileage as itemized above. I also herein certify that none of the mileage claimed was driven on personal business. Falsifying this report will be cause for dismissal.
28
For Dependent Contractor Only:
29
Purchase Order Number
30
Purchase Order Line Number
31
Payment Method Supplement
32
33
Total Miles Claimed:2025 Mileage Rate:Total $ Amount:
34
$0.700 $0.00I hereby certify that the total amount shown has been entered into TCS or SAP as an expenditure from the named individual.
35
Claimant (signature):Date:
36
By:
37
Approved By:
Date Entered:
38
Pay Period Entered or
SAP Document Number:
39
40
*Any person operating a motor vehicle to conduct County business must possess a valid County driver's permit. To obtain this permit, contact the driver's training coordinator within your department. For more information, go to intranet site www.sccgovatwork and find "County Vehicle Driver Poilcies and Training" under ESA>Risk Management>Insurance channel.
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100