Mileage Reimbursement
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La Grange School District Mileage Reimbursement
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Name:Current IRS Reimbursement Rate is $0.575 per mile
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Building:
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Month:
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Account Number:
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Directions: Save this file to your drive. Fill out the areas at the top of this form, except the account number. Please type the date in the fields below each of the blue days of the week. The mileage has already been calculated between each of the district buildings. Indicate, under each day, how many trips you made between any of the buildings. For example, if on Monday, you drove from Park to FR and then drove back to Park, you would put a 2 in the box under Monday in the row "Park-BR/FR". If you drove from Park to OG on the same day you would add a 1 in that column and row. The form will automatically calculate your total miles and reimbursement. If you have been approved for mileage to areas other than between schools, such as a conference or workshop, please enter the event under "Other Visits", enter the total mileage for the event under the "mileage" column, and then a 1 under the correct "day" column. (You are required to submit a copy of a map with this form for travel other than between buildings). Please print off the form and send to your supervisor for approval. Forms should be turned in biweekly.
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MTWThFssuMT WThFssu
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Enter dates in this row:
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LocationsmileageTotal miles
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Park-BR/FR2.10
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Park-CO0.90
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Park-CP1.90
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Park-OG0.30
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BR/FR-CO1.82113318
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BR/FR-CP2.2126.6
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BRFR-OG1.60
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CO-CP0.910.9
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CO-OG0.80
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CP-OG1.50
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Other Visits (Please attach supporting details, i.e. mapquest/googlemaps)
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Biweekly total mileage25.5
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Biweekly total reimbursed$14.79
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Approved by:
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Date:
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