Fillable Form 0.58: Personal Mileage Reimbursement Log (Louisiana Delta Community College)

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Form 0.58: Personal Mileage Reimbursement Log (Louisiana Delta Community College)

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Request Dat
e
Name Employee ID Invoice #
MILEAGE-MMMYY (abbr month & 2digits yr)
Address (one month per request)
City State Zip Code *** Attach a statement from your fleet manager stating no agency vehicle was available.
(this must be attached before reimbursement can be approved)
BEGINNING ENDING TOTAL REIMBURSEMENT LOCATION WHERE LOCATION
DATE OF TRIP ODOMETER READING ODOMETER READING MILES AMOUNT TRAVEL BEGAN TRAVELED TO PURPOSE OF TRIP
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$
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Total Miles
$
Tot
al Reimbursement
(Max 99 miles)
FUND ORGN ACCT PROG Activity Code
Date
Date
Date
Department Head Approval
Finance Approval
Personal Mileage Reimbursement Log
Employee Signature
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Form 0.58: Personal Mileage Reimbursement Log (Louisiana Delta Community College)

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Completed 16 September 2020

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