TRAVEL REIMBURSEMENT FORM
RNnetwork has agreed to reimburse you for travel associated with your nursing assignment. Reimbursement
will be at the maximum allowed IRS rate per mile (56¢ for 2021) up to the Travel Cap as determined in your
conrmation letter. Start/End Travel reimbursement will include only the mileage from your physical departure
address to your arrival address, limited to the Start/End Travel Cap amount. The Travel Reimbursement Form
must be received within 30 days of your arrival in order for you to receive reimbursement.
By signing this document, I attest the information to be truthful.
SIGNATURE DATE
Taxation Note: To ensure a mileage reimbursement is reported as a business travel expense and is not treated as taxable compensation, the IRS requires
this documentation of the business miles driven. In addition, to avoid taxation treatment, you must have a current qualifying Tax Home Representation Form
on le with RN Network, the assignment must not last more than one year, and the assignment must not be within commuting distance of your tax home.
Ofce Approval
ASSIGNMENT INFORMATION
Traveler Name:
Traveler Tax Home Address:
Assignment Start Date: Assignment End Date:
Facility Name:
Facility Address:
DEPARTURE INFORMATION
Departure Address:
ARRIVAL INFORMATION
Arrival Address:
CALCULATION
Miles from Departure Address to Arrival Address (Trip Date: )
IRS Allowed Rate Per Mile (subject to change) X $0.56
Calculated Amount = A
Travel Cap Amount (contained in your conrmation letter) = B
Travel Reimbursement Enter Lesser of A or B $
RNN Travel Form REV 12/2020 © RNnetwork 2020/12 RNN-810
