Employee Mileage and Reimbursement Form *MAKE A COPY TO USE*

	A	B	C	D	E	F	H	I	J	K	L	M	N	O
1	Employee Mileage and Reimbursement Form													Page 1
2	Sonoma County Office of Education
3	Name: (Claimant)
4	Name: (Claimant)						Date:					Mail Check?		YES
5												Mail Check?		NO
6	Department:						Fiscal Year:		-				Checks not mailed will be held in Business for pick up by employee.
7
8	Travel Month and Year: (Leave Blank if N/A)
9
10	Reimbursements
11
12	Receipt #	Date	Vendor					Description/Purpose						Amount
13	1
14	2
15	3
16	4
17	5
18	6
19	7
20	8
21	9
22	10
23	Original receipts are REQUIRED. Please write “receipt #” on each receipt (corresponds to receipt # column). Tape receipts to a separate piece of paper in the same order in which they are listed. If submitting part of a receipt, circle those items you are claiming and write the total on the receipt. Calculate sales tax (if any) and write on receipt. Total items you are claiming, plus sales tax, and circle on receipt.										(A) Total Reimbursements:			$ -
24											(A) Total Reimbursements:			$ -
25
26	Mileage (Page 1)
27
28	Date	DESTINATION				Mileage	Purpose
29	Date	From		To		Mileage	Purpose
30
31
32
33
34
35
36
37
38
39
40
41
42		Total of PAGE 1 Mileage:				0.00	x	$0.70	=	$0.00
43							x	IRS Rate Per Mile	=
44
45						0.00	x	$0.70	=	(B) Total Mileage:				$ -
46						Total Miles, All Pages	x	IRS Rate Per Mile	=	(B) Total Mileage:				$ -
47	Mileage Rates:									Total of PAGE 1 Mileage:				$ -
48	As of 1/1/25:		.70 / mile							Total of PAGE 2 Mileage:				$ -
49	1/1/24 - 12/31/24:		.67 / mile							Total of PAGE 3 Mileage:				$ -
50										Total of PAGE 4 Mileage:				$ -
51
52	Total Claim
53
54	By signing this form, claimant confirms that:	* Above data is a true and correct statement of actual and necessary expenses incurred while on official business for the Sonoma County Office of Education and that they have a current California Driver's License and auto insurance in effect (verification must be on file in Business Services); If an expense is disallowed due to lack of documentation or inappropriate expenses, claimant may be personally responsible for any improper costs incurred; Reimbursements listed have been made for materials and/or services that have been approved for SCOE purposes by the Superintendent OR Designee; *All purchased items are considered property of SCOE.									A+B = Total Claim			$ -
55
56	Account Codes
57	Grant / Budget Name:				Account Code:								Amount
58													$ -
59													$ -
60													$ -
61													$ -
62													$ -
63													$ -
64	REMINDER: PLEASE ATTACH ALL RECEIPTS										Total:		$ -
65											Out of Balance:		$ -
66
67	Claimant Signature									Date
68
69	Supervisor Signature									Date
70
71	Budget Manager Signature									Date
72
73	Asst Superintendent Signature									Date
74
75
76	BUS 4330.02													Revised August 2024