Shopping, Ci, Waiver, Bsb, Private Pay Mileage Reimbursement Form Page 2
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1
2Mileage Reimbursement Instructions
These items must be completed for your
Each line of time must include:
timesheet to be processed:
Service Date (MM/DD format)
Odometer Start (last 3 digits)
Employee Name
Odometer End (last 3 digits)
Employee ID (first 7 digits)
Total Mileage (round to nearest mile)
Member Name
Purpose of Trip
Member ID
Make sure your mileage form is filled out completely
Service Code
and correctly, with all entries made neatly inside the
Employee Signature & Date
boxes. Payment may be delayed if letters or numbers
Must be dated on or after the last day
o
are not printed neatly inside the boxes WITHOUT
worked.
touching any lines, or are not readable.
Member Signature & Date
Must be dated on or after the last day
o
Please continue on a second mileage form if you run
worked.
out of room on the first. Bold items on the list to the
left must also be filled in on the second form.
For best results use BLACK ink
Making Corrections
If you make a mistake before turning in your timesheet, cross out the incorrect line and
rewrite the information on the next blank line like this:
Do not write over the top of incorrect information like this:
If you make a mistake and the timesheet gets returned to you for corrections, you must fill
out a new timesheet.
Mileage Service Codes
Service
Enter As:
BSB
MILEAGE
CFC
CFCA0080
PAS
CFCA0080
Private Pay
MILEAGE
Waiver
MILEAGE
17775
Back page is for information only. Please do not submit it with your mileage form.
Revised 5/23/16
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