Mileage Reimbursement Claim Form
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1MILEAGE REIMBURSEMENT CLAIM FORM
Miles Driven January 1 – December 31, 2015
Name:
Emp. No.:
Home Address:
City:
Title:
Distance between home and headquarters:
Supervisor’s Name:
Division:
Claim Period:
Last Date Driven:
Date
Miles
Parking
Driven
Destination
Odometer
Claimed
Purpose of Trip
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 Reimbursement
Total Taxable Parking Fees: $
____
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: __________________
1/6/15
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