Gas Reimbursement Form
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1***Late forms will NOT be paid***
Trinity In-Home Care Gas - Reimbursement Form
Due the 1st and 16th of every month
Print Employee's Full Name:
Printed Client's Full Name:
Starting
Ending
Client
Date
# of miles Codes
Odometer
Odometer
Where did you go?
Initials
/
/
/
/
/
/
/
/
/
/
/
/
/
/
Total mileage
I hereby confirm that the information represented here is correct:
Employee's Signature:
Client/Responsible Party's Signature:
CODES
IE - In town Eudora Errand
Reimbursed per trip:
R - Trip to Rural Resident
IL - In town Lawrence Errand
Reimbursed Per Mile
E - Trip to Eudora
G - Grocery trip
O - Out of Town Errand
(To and from client's
B - Trip to Baldwin
M - Medical apt.
IB - In town Baldwin Errand
home)
Trinity In-Home Care - Gas Reimbursement Form
Due the 1st and 16th of every month
Print Employee's Full Name:
Printed Client's Full Name:
Starting
Ending
Client
Date
Odometer
Odometer
# of miles
Codes
Where did you go?
Initials
/
/
/
/
/
/
/
/
/
/
/
/
/
/
Total mileage
I hereby confirm that the information represented here is correct:
Employee's Signature:
Client/Responsible Party's Signature:
CODES
IE - In town Eudora Errand
Reimbursed per trip:
R - Trip to Rural Resident
IL - In town Lawrence Errand
Reimbursed Per Mile
E - Trip to Eudora
G - Grocery trip
O - Out of Town Errand
(To and from client's
B - Trip to Baldwin
M - Medical apt.
IB - In town Baldwin Errand
home)
***Late forms will NOT be paid***
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