WA N
F
EW
REEDOM
M
R
F
ILEAGE
EIMBURSEMENT
ORM
I
P
M
R
F
NDIVIDUAL
ROVIDER
ILEAGE
EIMBURSEMENT
ORM
MONTH: __ __ __
YEAR: 2 0 __ __
IP Name:
DAY
Number of Miles
IP Address:
1
2
3
* Check will be mailed to IP address listed above *
4
I have attached copies of the required documents:
5
Current Driver’s License
6
Current Auto Insurance Information
7
8
The authorization number for these services is:
9
AUL
10
11
12
IP Signature (required) – sign below
13
14
15
__ __ __
2 0 __ __
Date:
16
Month
Day
Year
17
Participant Signature (required) – sign below
18
19
20
__ __ __
2 0 __ __
21
Date:
Month
Day
Year
22
Please read the “Individual Provider Mileage
Reimbursement Form Instructions” for more
23
information on how to complete this form.
24
25
26
Also note: A W‐9 for must be completed the first
time you use this form. If you need a W‐9 form or if
27
you need to update your name or other information
28
on the W‐9 form after you submit it, please contact
29
PPL Customer Service at our toll‐free number:
30
1‐888‐866‐0642
31
TOTAL MILES
FAX OR MAIL THIS FORM TO PPL AT:
Fax: 1-866-484-2142
WA 98032
nd
Mail: ATTN: WA New Freedom, Public Partnerships, LLC, 20415 72
Ave. S. #450, Kent,
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Nov 2013_NF 2.0_v1.1