Month _____________ Employee Name ______________________________________________ PO #________
List any trips for school-related business with dates, purpose, total mileage and destination.
| DATE | PURPOSE | TOTAL MILEAGE | DESTINATION FROM | DESTINATION TO | “ √” IF ROUND TRIP |
Total Number of Miles _________ Reimbursement Rate $____________ Amount Due $____________
Claim for mileage reimbursement must be submitted no later than 30 days following June 30 of each school year.
Mileage Reimbursement estimated to be more than $250.00 annually per employee should be preceded by the issuance of a purchase order at the beginning of the school year.
Reimbursements not expected to exceed $250.00, may be claimed via Claim Form.
Employee Signature ______________________________________________
Supervisor Signature _____________________________________________
Adopted: January 2006
Amended: May 20, 2013
Amended: August 18, 2016