Fillable Personal Vehicle Use Auth Form (Montana State University - Northern)

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Personal Vehicle Use Auth Form (Montana State University - Northern)

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STATE OF MONTANA
PERSONAL VEHICLE USE
AUTHORIZATION FORM
1) Agency Number/Name
2) Division
3) Org Number
4) Name of Person(s) Traveling/Employee ID#
5) Justification for personal vehicle use
Driver of a personal vehicle on state business who is reimbursed mileage must comply with the applicable sections of the Motor
Vehicle Insurance Responsibility and Verification Act, Title 61, Chapter 6, Part 1 and Title 61, Chapter 6, Part 3, MCA, and must be aware
of personal vehicle usage liability as provided by the DOA Risk Management and Tort Defense Division.
6) Trip Itinerary (include dates)
7) Estimated Trip Miles
Use of a personal vehicle on state business is reimbursed at the standard mileage rate unless one of the conditions
listed below is met. Refer to the Employee Travel Policy for conditions and rates.
8) Rate Requested.
Standard Rate * High Rate ≤1,000 miles/mo * Low Rate >1,000 miles/mo
* If requesting reimbursement at the high or low rate, check the applicable reason below:
9) Traveler's Signature
Title
Date
Approval to be Completed by Agency Authorized Personnel
Rate Approved Standard High Low
Not Approved
Authorized Agency Official
Title
Date
Upon approval, the person(s) named above is granted authority to use a personal vehicle in the conduct of
official State business (in accordance with ARM 2.6.201 through ARM 2.6.214) within the basic confines of
the itinerary and approximate total mileage noted above.
REVISED 10/17
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Personal Vehicle Use Auth Form (Montana State University - Northern)

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Completed 23 July 2020

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