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Employee Name:__________________________________
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SHS to CO1.7 milesSMS to CO1.5 milesPV to CO0.7 miles
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PO Number: ___________________________________
SHS to PV2.3 milesSMS to PV1.1 milesPV to SHS2.3 miles
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SHS to SMS3.2 milesSMS to SHS3.2 milesPV to SMS1.1 miles
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Position: ___________________________________
SHS to SA
10.7 miles
SMS to SA
13.0 miles
PV to SA
12.3 miles
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SHS to MW
11.6 miles
SMS to MW8.6 milesPV to MW7.9 miles
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DateFrom ToPurposeMiles
SHS to GRADs
1.4 miles
SMS to GRADs
2.0 miles
PV to GRADs
1.2 miles
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SA to CO
11.5 miles
MW to CO8.6 milesCO to SHS1.7 miles
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SA to SHS
10.7 miles
MW to SHS
11.6 miles
CO to SMS1.5 miles
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SA to SMS
13.0 miles
MW to SMS8.6 milesCO to PV 0.7 miles
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SA to PV
12.3 miles
MW to PV7.9 milesCO to SA
11.5 miles
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SA to MW
19.1 miles
MW to SA
19.1 miles
CO to MW8.6 miles
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SA to GRADs
11.0 miles
MW to GRADs
8.9 miles
CO to GRADs
0.5 miles
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GRADs to SHS
1.4 miles
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GRADs to SMS
2.0 miles
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GRADs to PV
1.2 miles
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GRADs to SA
11.0 miles
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GRADs to MW
8.9 miles
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GRADs to CO
0.5 miles
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Total miles traveled for the month of _______________:0
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Total amount to be reimbursed at $0.70/mile:
$ -
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I certify that I did travel the distances listed above in the discharge of my responsibilities in the
position indicated above.
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______________________________________
_______________
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Employee Signature
Date
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______________________________________
_______________
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Supervisor Signature
Date
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Note: It is required that this form be completed monthly. Any exceptions must be approved by the
Executive Director of Finance.
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