Rev 08/07
Louisiana State University
Office of Accounting Services
Payroll
204 Thomas Boyd Hall
COURTESY CAR DECLARATION AS570
Month / Year _____________________
Check applicable statement: Same Vehicle Initial Report New Vehicle
------------------------------------------------------------------------------------------------------------------------------
FOR ACCOUNTING SERVICES USE ONLY
___________ x _____________ / 12 months = ______________ | ____________ x $3/day = _________________
Annual Lease Personal Use % | Commuting Days
Value |
|
Personal Use Fuel Charge: |
________________ x 5.5 cents = _______________ |
Personal Miles |
Employee (Last, First, MI)
LSU ID Driver’s License #
Department
Phone Fax E-mail
Year Color
Make Model
Value Serial # License #
Vehicle Assigned for Commuting Only
Beginning Odometer Reading
Ending Odometer Reading
Average Daily Round Trip
Commuting Distance
Number of Days Commuting
Affidavit
I certify that the courtesy car provided to me was used
for commuting only and was not used for personal
pu
rposes. I further certify that I have records to
substantiate the above reported utilization and that such
record will be retained by me for seven years and made
available when needed.
_________________________ _____________
Signature Date
Vehicle Assigned for Business or Personal Use
and/or Control Employee
Business Mileage
Personal Mileage
Total Mileage
Affidavit
I certify that I have records to substantiate the above
reported utilization and that such re
cords will be retained by
me for seven years and made available when needed.
_____________________________ ____________
