Participant-Hired Worker Mileage Log Sample
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1SAMPLE
Participant-hired Worker Mileage Log
Instructions: 1. Participant-hired worker completes one entry for each trip.
2. Participant-hired worker and participant employer sign at the bottom.
3. Please note mileage to the doctor cannot be reimbursed.
123456
July 2015
2
1
Service Month and Year: _____________________ Participant-hired Worker Number: __________________
John Doe
3
Print Participant-hired Worker Name: __________________________________________________________
John Smith
4
Print Participant Employer Name: _____________________________________________________________
Total
Date
From
To
Purpose
Miles
Church
15
5
Faith Church Sussex
7/2
Home
15
7/2
Faith Church Sussex
Home
Home
7/3
Groceries
Layton Grocery Store
5
123 W. Street
Home
Layton Grocery Store
123 W. Street
7/3
5
123 W. Street
Visit Friend
8.5
456 N. 2nd Street
7/8
456 N. 2nd Street
123 W. Street
Home
8.5
7/8
789 N. 3rd Street
Visit Friend
12.25
123 W. Street
7/10
789 N. 3rd Street
123 W. Street
Home
12.25
7/10
Areas that must be filled out:
1 = Service Month and Year
2 = Participant-hired Worker Number
3 = Participant-hired Worker Name
4 = Participant Employer Name
5 = Mileage information (Date of trip, From and To destinations, Purpose of trip, and Total Miles of trip).
From and To destinations may be specific addresses or general places (such as Home or Church).
6 = Total Miles (for all trips)
7 = Participant-hired Worker Signature and Date
8 = Participant Employer Signature and Date
6
81.5
Total Miles:
John Doe
7/29/2015
7
Participant-hired Worker Signature: ___________________________________________ Date: ___________
John Smith
7/31/2015
8
Participant Employer or Guardian Signature: ____________________________________ Date: __________
Mileage logs should be submitted with
Important:
iLIFE
time reports after a given pay period.
Both signature dates must be on or later than the last trip
Harry and Jeanette Weinberg Building ● 2020 West Wells Street, Milwaukee, WI 53233 ● Phone: 1-888-800-5599
date, and signature dates must be listed in mm/dd/yyyy
Fax: 414-937-2034 ● Email: ● Website:
format.
P-FS0024 (5/2015)
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Parent category: Miscellaneous