Maintenance And Operating Supplies Reimbursement Form
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1Maintenance and Operating Supplies
Reimbursement Form
* A $12.00 service charge will be applied to all preventable reimbursements.
Vehicle Information
Vehicle #:
_____________________________
Gas Card #:
_____________________________
Employee Information
Name:
_____________________________
Address:
____________________________
Office Phone:
_____________________________
____________________________
Cell Phone:
_____________________________
City, State, Zip:
____________________________
Purchase Information
Date:
__________________________
Explanation of Purchase: ______________________
__________________________________________
Vehicle Mileage:
__________________________
__________________________________________
Vendor Name:
__________________________
__________________________________________
Vendor Address:
__________________________
__________________________________________
__________________________
__________________________________________
City, State, Zip:
__________________________
__________________________________________
Purchase Amount: __________________________
Why wasn’t ARI or GasCard used for the purchase?
Price per Gallon:
____________________
(fuel only)
__________________________________________
Signatures
__________________________________________
__________________________________________
Employee:
_________________________
__________________________________________
Supervisor:
_________________________
__________________________________________
Date:
_________________________
In order to receive a reimbursement, please mail this completed form, with the original receipt, to the appropriate
address.
Non-Fuel Reimbursement
Fuel Reimbursement
Division of Fleet Operations – Fuel Network
Division of Fleet Operations
Attn: Paul Ferguson
Attn: Jeff Done
P.O. Box 141117
P.O. Box 141117
Salt Lake City, UT 84114-1117
Salt Lake City, UT 84114-1117
4120 State Office Building • Salt Lake City, Utah 84114-1153
Phone: (801) 538-3014 • Fax: (801) 359-0759 •
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Parent category: Business