Mileage Reimbursement Form FY22

	A	B	C	D	E	F	G
1	ACSD
2	MILEAGE REIMBURSEMENT FORM
3	Travel forms must be submitted monthly or may be taxable wages per IRS requirements.
4	School Responsible for Payment:					0.585	Mileage Rate
5	Driver Name:						as of: 1/1/22
6
7	Month:			Fiscal Year:	2021-2022
8
9		FROM	TO			Cost	Total
10	DATE	TOWN	TOWN	DESCRIPTION/PURPOSE	MILES	Per Mile	for trip
11	Mileage Reimbursement (if driving to/from home directly, please deduct regular commute to/from work)
12						0.585	$ -
13						0.585	$ -
14						0.585	$ -
15						0.585	$ -
16						0.585	$ -
17						0.585	$ -
18						0.585	$ -
19						0.585	$ -
20						0.585	$ -
21						0.585	$ -
22						0.585	$ -
23						0.585	$ -
24						0.585	$ -
25						0.585	$ -
26						0.585	$ -
27						0.585	$ -
28	Parking/Other Travel Reimbursement Requests (attach receipts)
29							$ -
30							$ -
31
32
33
34				Mileage total	0	0.585	$ -
35				Parking/other reimbursement			$ -
36				Total Reimbursement			$ -
37	DRIVER CERTIFICATION
38	By signing below, I certify that, at the time of the above travel, I had a valid driver's license, had auto insurance, and included an accurate mileage for school district travel.
39	In addition, I will advise my Supervisor if either my driver's license or my auto insurance is suspended/canceled prior to future school travel.
40	Driver Signature:				DATE:
41
42	APPROVAL FOR PAYMENT
43	ADMINISTRATOR APPROVAL:				DATE:
44
45	ACCOUNT #:
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