MileageClaimForm.xls
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ABCDEFGHIJKLMNOPQRSTUVWXYZ
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MILEAGE CLAIM FORM
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Section 2 of the NYSPHSAA, Inc.
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433 Broadway, Suite 301
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Saratoga Springs, NY 12866
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Date: _________________Name: ________________________________
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Address: ________________________________
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Committee: ______________ ________________________________
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PeriodFrom: ___________To: _____________Rate/Mile:$0.53
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DateFromToMileagePurpose
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Total:0 X$0.53 0
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(mileage)(Rate)(Total Due)
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Note: Mileage is actual not estimated, rounded to the nearest tenth of a mile.
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Origin and destination locations must be specific to verify actual mileage claimed.
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Mileage claims must be submitted in the school year incurred.
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I certify that the above bill is just, true and correct; that no part has been paid except as stated,
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and that taxes from which Section 2 is exempt are excluded.
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DATE
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Signature of Claimant
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Approval of Executive Director.
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Approval of Internal Control Officer
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July 2014
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