Employee Mileage Reimbursement Form - Free Download
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MILEAGE REIMBURSEMENT CLAIM FORM
Miles Driven January 1 – December 31, 2015
Distance between home and headquarters:
Last Date Driven:
Purpose of Trip
IF MORE THAN ONE SHEET IS USED, DETACH ON HEAVY LINE, EXCEPT LAST SHEET OF CLAIM.
Falsifying this report will be cause for dismissal.
Total Non-Taxable Miles Driven:
______ @ 57.5¢ = $
Total Taxable Miles Driven:
___________ = $
Total Non-Taxable Parking Fees: $
Total Taxable Parking Fees: $
I HEREBY CERTIFY that the mileage reimbursement claimed on this form are proper and actual mileages and parking fees
incurred during this period and in accordance with LACERA’s Mileage Reimbursement Policy.
Employee Signature: ___________________________________________________ Date: _______________________
Approval Signature: ____________________________________________________ Date: _______________________
Date Submitted for Reimbursement: __________________