Appendix B.3 - Sample Timesheet And Mileage Request Form printable pdf download

Appendix B.3 - Sample Timesheet And Mileage Request Form

Appendix B.3 - Sample Timesheet and Mileage Request Form

Appendix B.3 – Sample Timesheet and Mileage Request Form

TIMESHEET and MILEAGE REIMBURSEMENT REQUEST

Physical Address: 123 State Street,

Mailing Address: PO Box 123, Our Town, USA 81234

Our Town, USA

81234 Telephone: (555) 555-1234

Fax: (555) 555-5555

Return to the RSVP Office by the 10

of the following month

Volunteer Name (Print)

_ Month

, 20

Mailing Address

City/Zip

Station Name

Auto Insurance Information on File? Y or N

Date

Volunteer Assignment

# of

^Start

^End

Auto

*Meals

Enter MP if you a

Hours

Odometer

miles

meal was provided

while serving, BB if

you brought a brown

bag meal or the

actual expense if you

paid for a meal and

request

reimbursement.

Leave blank if no

meal is received

Meals will be

reimbursed

consistent with

sponsor policy.

^Enter actual start

and stop odometer

readings for each

trip.

IMPORTANT!

Please obtain your

volunteer station

supervisor’s original

signature before

submitting

For Office Use

Only:

Mileage

Reimbursement

_______ miles X

______ per mile =

Total Reimbursement:

TOTALS

VOLUNTEER: By signing below, I certify that this statement and the amount claimed are true, correct and complete to the best of my knowledge.

I certify that I possessed a valid driver’s license and that liability insurance in the minimum amount required by law was in force at the time of this

travel. STATION SUPERVISOR: By signing below, I certify that to the best of my knowledge this claim is correct and true.

RSVP Volunteer Signature

Date

Station Supervisor Signature

Date

RSVP Staff Signature

Date

Version 2017.4

Pg. 1 of 1

This document is provided as a sample ONLY. Its use is optional and, if used, it should be customized as appropriate. For all appendices,

including editable versions of samples and templates, visit https://

Appendix B.3 - Sample Timesheet And Mileage Request Form

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