MONTHLY MILEAGE REPORT
1. MONTH ENDING 2. LICENSE PLATE NO.
STATE OF NEW JERSEY
SG
Department of The Treasury - Transportation Services
(Month) (Day) (Year)
INSTRUCTIONS: Please print or type. Submit completed report to the Department of the Treasury-Division of Administration-Transportation
Services within 5 days of the end of the month. This report must be signed by the individual designated in item 10 below.
3. ODOMETER (Beginning of month) 4. ODOMETER (End of month) 5. COMMUTING MILES TRAVELED THIS MONTH
(Enter all miles traveled between employee residence and official work station.)
• • •
(Miles) (Tenths) (Miles) (Tenths) (Miles) (Tenths)
6. NUMBER WEEKDAYS 7. CHECK HERE IF LEAVE BLAN
(Transportation Services Use Only)
ASSIGNED IN MONTH NEW ODOMETER Correction:
8. DEPARTMENT 9. DIVISION
10. TYPE OF VEHICLE ASSIGNMENT (Check one box only. Enter name of driver if individually assigned or coordinator if pool vehicle.)
Individually Assigned: (or) Pool Vehicle:
(Name of Driver) (Name of Coordinator )
CERTIFICATION: I certify that all report information is complete and accurate to the best of my knowledge.
Driver/Coordinator Signature: Phone #: Date:
ADMV-104 rev 6/2009
MONTHLY MILEAGE REPORT
1. MONTH ENDING 2. LICENSE PLATE NO.
STATE OF NEW JERSEY
SG
Department of The Treasury - Transportation Services
(Month) (Day) (Year)
INSTRUCTIONS: Please print or type. Submit completed report to the Department of the Treasury-Division of Administration-Transportation
Services within 5 days of the end of the month. This report must be signed by the individual designated in item 10 below.
3. ODOMETER (Beginning of month) 4. ODOMETER (End of month) 5. COMMUTING MILES TRAVELED THIS MONTH
(Enter all miles traveled between employee residence and official work station.)
• • •
(Miles) (Tenths) (Miles) (Tenths) (Miles) (Tenths)
6. NUMBER WEEKDAYS 7. CHECK HERE IF LEAVE BLAN
(Transportation Services Use Only)
ASSIGNED IN MONTH NEW ODOMETER Correction:
8. DEPARTMENT 9. DIVISION
10. TYPE OF VEHICLE ASSIGNMENT (Check one box only. Enter name of driver if individually assigned or coordinator if pool vehicle.)
Individually Assigned: (or) Pool Vehicle:
(Name of Driver) (Name of Coordinator )
CERTIFICATION: I certify that all report information is complete and accurate to the best of my knowledge.
Driver/Coordinator Signature: Phone #: Date:
ADMV-104 rev 6/2009
MONTHLY MILEAGE REPORT
1. MONTH ENDING 2. LICENSE PLATE NO.
STATE OF NEW JERSEY
SG
Department of The Treasury - Transportation Services
(Month) (Day) (Year)
INSTRUCTIONS: Please print or type. Submit completed report to the Department of the Treasury-Division of Administration-Transportation
Services within 5 days of the end of the month. This report must be signed by the individual designated in item 10 below.
3. ODOMETER (Beginning of month) 4. ODOMETER (End of month) 5. COMMUTING MILES TRAVELED THIS MONTH
(Enter all miles traveled between employee residence and official work station.)
• • •
(Miles) (Tenths) (Miles) (Tenths) (Miles) (Tenths)
6. NUMBER WEEKDAYS 7. CHECK HERE IF LEAVE BLAN
(Transportation Services Use Only)
ASSIGNED IN MONTH NEW ODOMETER Correction:
8. DEPARTMENT 9. DIVISION
10. TYPE OF VEHICLE ASSIGNMENT (Check one box only. Enter name of driver if individually assigned or coordinator if pool vehicle.)
Individually Assigned: (or) Pool Vehicle:
(Name of Driver) (Name of Coordinator )
CERTIFICATION: I certify that all report information is complete and accurate to the best of my knowledge.
Driver/Coordinator Signature: Phone #: Date:
ADMV-104 rev 6/2009
