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This form is to be used when there is a PO already prepared.
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Use a Claim form when there is no PO
Name:
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Month/Year:
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Building Assignment:
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PO Number
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Google Maps directions are REQUIRED for any trips not listed on district mileage chart.
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Effective January 1, 2025, the reimbursable mileage rate is .70 cents per mile.
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DateDescriptionTolls*StartingStop AStop BEndingRT?Mileage
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Total Mileage
0.00
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Rate
0.70
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*EZ Pass Statement/Toll Receipt with supervisor's initials REQUIRED for toll reimbursement
Reimbursement Total - Mileage
$0.00
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Tolls
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Total Reimbursement
$0.00
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