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Burlington County Institute of Technology
Mileage Report
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Expense Reimbursement
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Employee Name:
Month(s)
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Campus:
Extension #:
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Rate per Mile$0.47
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DateTimeAddress of Starting LocationAddress of DestinationExpense Type/ Purpose of TripMiles Driven$
Amount
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$0.00
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$0.00
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$0.00
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$0.00
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$0.00
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$0.00
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$0.00
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$0.00
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$0.00
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$0.00
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$0.00
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$0.00
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$0.00
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$0.00
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$0.00
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$0.00
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$0.00
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$0.00
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$0.00
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$0.00
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$0.00
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NON-MILEAGE RECEIPTS ARE RECORDED BELOW:
AMT
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Total Miles/Total Reinbursement$0.00
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CLAIMANT'S CERTIFICATION AND DECLARATION
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I do solemnly declare and certify under the penalties of the law that the within bill is correct in all its particulars; that the articles have been furnished or services rendered as stated therein; that no bonus has been given or received by any person or persons within the knowledge of this claimant in connection with the above claim; that the amount therein stated is justly due and owing; and that the amount charged is a reasonable one.
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Employee's Signature Date____Approved____Disapproved
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Supervisor's Signature Date
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Account #
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