Pasadena Area Community College
District Mileage Reimbursement - Use Of Private Vehicle
CHARGE TO
FUND COST CTR OBJECT PROGRAM
TOTAL MILEAGE
X ___________ = $
PARKING FEES
(Original Receipts Required)
TOTAL AMOUNT OF CLAIM $
submit original form with original receipts (as appropriate) to Fiscal Services. Please keep a copy for your records/reference.
Fiscal Services 10/2017
This report is to be submitted to Fiscal Services (C203) on a monthly basis.
TO (CITY)
DESTINATION/
PURPOSE
Retain one copy for your files
RESIDENTIAL
ADDRESS
(REQUIRED)
NAME
Mileage is calculated from the college or employee's residence (whichever is less).
FOR THE MONTH OF
MILES TRAVELEDDATE FROM (CITY)
"I certify that the foregoing is a true and correct statement of the use of my personal automobile for the necessary travel performed by
me in carrying out my assigned duties as an employee of the Pasadena Area Community College District."
EMPLOYEE SIGNATURE
EMPLOYEE ID #
DEPARTMENT
DATE
COST CENTER MANAGER
DATE
0
0.58
$ 0.00
0.00