Fillable VEHICLE REQUEST AND ASSIGNMENT REPORT (NJ Department of Treasury)

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VEHICLE REQUEST AND ASSIGNMENT REPORT (NJ Department of Treasury)

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The VEHICLE REQUEST AND ASSIGNMENT REPORT (NJ Department of Treasury) form is 1 page long and contains:

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  • 13 check-boxes
  • 38 other fields

Country of origin: US
File type: PDF

U.S.A. forms for NJ Department of Treasury

BROWSE NJ DEPARTMENT OF TREASURY (NJ) FORMS

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STATE OF NEW JERSEY
DEPARTMENT OF THE TREASURY
DIVISION OF ADMINISTRATION - TRANSPORTATION SERVICES
VEHICLE REQUEST AND ASSIGNMENT REPORT
1. DEPT.
2. DRIVER’S LAST NAME (If pool car, enter location and city) 3. ODOMETER 4. VIP Confidential 5. STATE PLATE
6. DIV
(Please check one)
7. ACCOUNT OR BUDGET CODE
8. DRIVER’S LICENSE NUMBER
(If pool car, enter supervisor’s last name)
9. DRIVER’S EMPLOYEE ID #
(If pool car, skip item 9)
New Ext.
From
10. ASSIGNMENT TYPE: Check one. Note: If Temporary request, enter dates and check new or Extension)
Cabinet Executive Other Individual Agency Pool Non-Reporting Equipment Temporary
Is this an existing
assignment? Enter date
the assignment started
To
Date
11. INDIVIDUALLY ASSIGNED? (Is the overnight parking location your home If yes, complete items
a thru I if not fill out box 12)
12. AGENCY POOL OR FLEET
VEHICLE? e. Overnight Storage Location:
a. Driver’s
Name:
f. Number of Miles from Residence (If yes, complete items a to h)
b. Home
Address: to Work Station: a. Name of Vehicle Coordinator: Street:
g. Commuting Trips: City: State:
c. Title: h. Commuting Miles: b. Title: f. Number of Miles from Storage Location
d. Range: Work Phone: i. Business Miles: c. Office Phone: to Work Station:
e. Official Work Station: City & county) d. Business Miles: g. Commuting Trips:
h. Commuting Miles:
13. JUSTIFICATION FOR ASSIGNMENT:
14. Certification:
Signature, Chief Administrative Officer Date
Bureau Use Only
Assignment Date Repair Location Repair Priority Rotated For Approved Disapproved
Signature and Date
ADMV-103 rev 6/2009 **PLEASE SEE COMPLETE INSTRUCTIONS
INSTRUCTIONS
ITEM
1. Department submitting document.
2. If individually assigned, enter driver’s last name, if pool vehicle enter office location and city.
3. Enter the vehicle’s odometer, if applicable, at the time of the transaction.
4. If so equipped, enter the VIP or confidential plate number and check the appropriate box.
5. Vehicle’s state plate number (include the appropriate prefix, i.e., SG, TD, or SP.)
6. Division submitting document.
7. Account number or Budget Code to which vehicle is to be billed.
8. If indivudally assigned, enter driver’s license number, if pool vehicle enter supervisor’s last name.
9. If individually assigned, enter driver’s employee ID number, if pool vehicle leave blank.
10. Type of assignment, check one. Before completing section 10 consult State Vehicular Assignment and Use Policy. The distinction among types of assignments is
crucial to the Bureau of Transportation Services.
11. Complete this section only if individually assigned.
a. through f. Fill in information as indicated.
g. Number of times during the month that the vehicle is driven directly from the residence to the official work station, PLUS the number of times that vehicle is
driven directly from official work station to the residence. (This number could range from 0 to 44.)
h. Multiply 11g. by 11f.
i. Enter all mileage when vehicle is not being driven directly to and from residence and official work station.
12. a. through e. Fill in information as indicated.
f. through h. Complete if vehicle is stored off site for security reasons.
(Note: Attach justification for off site storage.)
f. As indicated.
g. Number of times during the month that vehicle is driven directly to the storage location from the official work station, PLUS the number of times that vehicle is
driven directly from the official work station to the storage location. (This number could range from 0. to 44.)
h. Multiply 12f. by 12g.
13. Justification—Before completing section 13, please consult State Vehicular Assignment and Use Policy. Explain in detail why the vehicle is needed. Be as specific
as possible as to employee job function or agency’s responsibilities. Any change of assignment requires rejustification.
14. Certification – Certify that above information is accurate and that funds are available to cover the cost of the vehicle.
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VEHICLE REQUEST AND ASSIGNMENT REPORT (NJ Department of Treasury)

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Completed 13 August 2020

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