Employee Mileage Reimbursement Form - Free Download
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MILEAGE REIMBURSEMENT CLAIM FORM
Miles Driven January 1 – December 31, 2015
Name:
Emp. No.:
Home Address:
City:
Title:
Distance between home and headquarters:
Division:
Supervisor’s Name:
Claim Period:
Last Date Driven:
Date
Driven
Destination
Odometer
Miles
Claimed
Purpose of Trip
Parking
Fees
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: $
____
Total Reimbursement
Claimed:
$
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: _______________________
(Supervisor/Manager)
Date Submitted for Reimbursement: __________________
