Mileage Reimbursement 2011-2012

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Mileage Reimbursement 2011-2012 Powered By Docstoc
					Odometer Only                                            Mileage Reimbursement 2011-12
                                                                        Revised 8/9/11                         PLEASE enter below your account code and the percent funding.
                                                                                                                          (Enter the number 100 for 100%, and so on).
                                                                                                               Account Code                                  %             Dollars
School or Department                                       Traveler Name and Title

                             Other:

Work # /Cell/ Home Phone #                                 or
For The Period From:                                     To:




                                      THE FOLLOWING INFORMATION IS TO BE ITEMIZED ON A DAILY BASIS                                                       Claim Total:
                   Private Vehicle Mileage Only       Rnd Private Vehicle Mileage Only
   Date         Departed From             Arrived at   Trip Odometer Reading                                                                         Purpose
                  Location                 Location    Y/N           Start             End    Mileage
                                                                                                                      -
                                                                                                                      -
                                                                                                                      -
                                                                                                                      -
                                                                                                                      -
                                                                                                                      -
                                                                                                                      -
                                                                                                                      -
                                                                                                                      -
                                                                                                                      -
                                                                                                                      -
                                                                                                                      -
                                                                                                                      -
                                                                                                                      -
                                                                                                 Totals               -              FINANCIAL SERVICES USE ONLY
                                                                                               Rate per mile     $0.445        Received               _____________________
                                                                                               Page Total                      Received               _____________________
Date:                                                                                          Claim Total                     Received               _____________________


In signing this reimbursement claim, I hereby attest that I, the Traveler, have maintained the minimum vehicle insurance levels required by law
in the State of Arizona. I further attest that the insurance was in effect for the period in which mileage reimbursement has been claimed. I recognize that failure to
comply with state law and Governing Board policy in this regard may result in disciplinary action up to and including dismissal.

I also certify that the travel was accomplished in the performance of official duties; that the information given is true in all
respects and that no claim against the district has before been made for any part thereof, or paid from any other source of funding.

                                                                                                                                                                         ____________
                 (Signature of Traveler)                                                                                    (Signature of Authorized Official)             (Date)
            BASIC INSTRUCTIONS FOR MILEAGE SPREADSHEET


Thank you for using the automated "Mileage Form" reimbursement workbook. It's a big
time-saver administratively and when you use the form we can get you your payment more quickly.

Account Code(s) and Percentage(s) must be included on claims and Insurance

INCOMPLETE SUBMISSIONS AND SUBMISSION THAT DO NOT BEGIN ON PAGE 1, WILL BE RET

FIRST: Print these instructions and READ them. Note the series of "file tabs" at the bottom of this
sheet. Each file tab you see (eg. "Page 1 ", "Page 2 ", etc.) is a separate sheet.

SECOND: Enter your name and the other personal info requested on top of "Page 1 ".

Hitting the TAB KEY will automatically take you to where you should enter the personal information that m
appear on every claim.

(Oops! If you got a message saying the spreadsheet is password protected, it is because you are at a lo
where you are not meant to enter data. REREAD THE SECOND INSTRUCTION regarding the TAB KEY
spreadsheets are password-protected except for areas where the traveler needs to enter information.)

THIRD: Now save the file in which you've entered your personal info and only your personal information
After entering travel details, save that claim separately (eg. "Claim One.xls.) Alwarys return to the
file which only has your personal information when you wish to file a new claim. Keeping a clean copy of
"Mileage Form" with only your personal information filled in saves you time!

FOURTH: If you travel frequently, use the option of completing up to 15 pages of claims before
returning to your archived file and starting over. Please, continue to submit your claims on a
monthly or quarterly basis so we are not deluged by claims at the end of the year.

FIFTH: Print each page separately after you've completed it. DO NOT skip pages. Note:
you will see mileage totals for each page and a grand total for the claim on "Page 1 ".

For travelers who don't travel between locations on the District Mileage Chart, on the "Odometer
Reported Mileage Only " sheet you may type in locations in the columns labeled "DEPARTED
FROM LOCATION" and "ARRIVED AT LOCATION" as well as your odometer readings. You can
only do this on the "Odometer Reported Mileage Only " sheet. Use the "Odometer Reported
Mileage Only " sheet exclusively for travel not included on the District Mileage Chart. If your travel
only occasionally includes locations not on the district chart, you may want to enter both
"odometer travel" and in-district travel on the automated spreadsheets.

PRINTING. When you are ready to print, simply click on the printer icon on your tool bar
and print each page. Each page (with the exception of "Odometer Reported Mileage Only" )
will say which page it is of the total. For example, in a six page claim the second page will say
"Page 2 of 6". For your claim to be approved, you must submit all six pages.
 our payment more quickly.



 GIN ON PAGE 1, WILL BE RETURNED.

 tabs" at the bottom of this




er the personal information that must


 ted, it is because you are at a location
UCTION regarding the TAB KEY.The
er needs to enter information.)

d only your personal information.
xls.) Alwarys return to the
w claim. Keeping a clean copy of the


pages of claims before
mit your claims on a




Chart, on the "Odometer
s labeled "DEPARTED
meter readings. You can
 "Odometer Reported
ileage Chart. If your travel




orted Mileage Only" )
 second page will say
Page 1                                                                 Mileage Reimbursement 2011-12
                                                                     Revised 8/9/11                                             PLEASE enter below your account code and the percent funding.
                                                                                                                                           (Enter the number 100 for 100%, and so on).
                                                                                                                                Account Code                                 %
School or Department                                                     Traveler Name
                                 Title:

Work # /Cell/ Home Phone #                                              or
For The Period From:                                                   To:




                                          THE FOLLOWING INFORMATION IS TO BE ITEMIZED ON A DAILY BASIS                                                                      Claim Total:
                   Private Vehicle Mileage Only                   Rnd    Private Vehicle Mileage Only
   Date          Departed From                   Arrived at       Trip   Odometer Reading                                                                                Purpose
                   Location                       Location        Y/N       Start                  End                           Mileage
                                                                                                                                       -
                                                                                                                                       -
                                                                                                                                       -
                                                                                                                                       -
                                                                                                                                       -
                                                                                                                                       -
                                                                                                                                       -
                                                                                                                                       -
                                                                                                                                       -
                                                                                                                                       -
                                                                                                                                       -
                                                                                                                                       -
                                                                                                                                       -
                                                                                               Miles                                   -                FINANCIAL SERVICES USE ONLY
                                                                                               Rate per mile                      $0.445          Received               ______________
                                                                                               Total Miles                             -          Received               ______________
Date:                                                                                          Claim Total                           $0.00        Received               ______________


In signing this reimbursement claim, I hereby attest that I, the Traveler, have maintained the minimum vehicle insurance levels required by law
in the State of Arizona. I further attest that the insurance was in effect for the period in which mileage reimbursement has been claimed. I recognize that failure to
comply with state law and Governing Board policy in this regard may result in disciplinary action up to and including dismissal.

I also certify that the travel was accomplished in the performance of official duties; that the information given is true in all
respects and that no claim against the district has before been made for any part thereof, or paid from any other source of funding.


                (Signature of Traveler)                                                                                                      Signature of Authorized Official                   (Da
nding.
n).
        Dollars
        $0.00
        $0.00
        $0.00
        $0.00
        $0.00


        $0.00




ONLY
_______________
_______________
_______________




      ____________
         (Date)
Page 2




                                   CLAIMS MUST BEGIN ON "Page 1" OR THEY WILL BE RETURNED.



                                  THE FOLLOWING INFORMATION IS TO BE ITEMIZED ON A DAILY BASIS
                   Private Vehicle Mileage Only   Rnd Private Vehicle Mileage Only
   Date        Departed From          Arrived at   Trip Odometer Reading                                                                           Purpose
                 Location              Location    Y/N           Start             End    Mileage
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                               Miles                -               FINANCIAL SERVICES USE ONLY
                                                                                                                              Received               _____________________
                                                                                                                              Received               _____________________
Date:                                                                                                                         Received               _____________________


In signing this reimbursement claim, I hereby attest that I, the Traveler, have maintained the minimum vehicle insurance levels required by law
in the State of Arizona. I further attest that the insurance was in effect for the period in which mileage reimbursement has been claimed. I recognize that failure to
comply with state law and Governing Board policy in this regard may result in disciplinary action up to and including dismissal.

I also certify that the travel was accomplished in the performance of official duties; that the information given is true in all
respects and that no claim against the district has before been made for any part thereof, or paid from any other source of funding.

                                                                                                                                                                         ____________
                (Signature of Traveler)                                                                                   (Signature of Authorized Official)               (Date)
Page 3




                                   CLAIMS MUST BEGIN ON "Page 1" OR THEY WILL BE RETURNED.



                                  THE FOLLOWING INFORMATION IS TO BE ITEMIZED ON A DAILY BASIS
                   Private Vehicle Mileage Only   Rnd Private Vehicle Mileage Only
   Date        Departed From          Arrived at   Trip Odometer Reading                                                                           Purpose
                 Location              Location    Y/N           Start             End    Mileage
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                               Miles                -               FINANCIAL SERVICES USE ONLY
                                                                                                                              Received               _____________________
                                                                                                                              Received               _____________________
Date:                                                                                                                         Received               _____________________


In signing this reimbursement claim, I hereby attest that I, the Traveler, have maintained the minimum vehicle insurance levels required by law
in the State of Arizona. I further attest that the insurance was in effect for the period in which mileage reimbursement has been claimed. I recognize that failure to
comply with state law and Governing Board policy in this regard may result in disciplinary action up to and including dismissal.

I also certify that the travel was accomplished in the performance of official duties; that the information given is true in all
respects and that no claim against the district has before been made for any part thereof, or paid from any other source of funding.

                                                                                                                                                                         ____________
                (Signature of Traveler)                                                                                   (Signature of Authorized Official)               (Date)
Page 4




                                   CLAIMS MUST BEGIN ON "Page 1" OR THEY WILL BE RETURNED.



                                  THE FOLLOWING INFORMATION IS TO BE ITEMIZED ON A DAILY BASIS
                   Private Vehicle Mileage Only   Rnd Private Vehicle Mileage Only
   Date        Departed From          Arrived at   Trip Odometer Reading                                                                           Purpose
                 Location              Location    Y/N           Start             End    Mileage
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                               Miles                -               FINANCIAL SERVICES USE ONLY
                                                                                                                              Received               _____________________
                                                                                                                              Received               _____________________
Date:                                                                                                                         Received               _____________________


In signing this reimbursement claim, I hereby attest that I, the Traveler, have maintained the minimum vehicle insurance levels required by law
in the State of Arizona. I further attest that the insurance was in effect for the period in which mileage reimbursement has been claimed. I recognize that failure to
comply with state law and Governing Board policy in this regard may result in disciplinary action up to and including dismissal.

I also certify that the travel was accomplished in the performance of official duties; that the information given is true in all
respects and that no claim against the district has before been made for any part thereof, or paid from any other source of funding.

                                                                                                                                                                         ____________
                (Signature of Traveler)                                                                                   (Signature of Authorized Official)               (Date)
Page 5




                                   CLAIMS MUST BEGIN ON "Page 1" OR THEY WILL BE RETURNED.



                                  THE FOLLOWING INFORMATION IS TO BE ITEMIZED ON A DAILY BASIS
                   Private Vehicle Mileage Only   Rnd Private Vehicle Mileage Only
   Date        Departed From          Arrived at   Trip Odometer Reading                                                                           Purpose
                 Location              Location    Y/N           Start             End    Mileage
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                               Miles                -               FINANCIAL SERVICES USE ONLY
                                                                                                                              Received               _____________________
                                                                                                                              Received               _____________________
Date:                                                                                                                         Received               _____________________


In signing this reimbursement claim, I hereby attest that I, the Traveler, have maintained the minimum vehicle insurance levels required by law
in the State of Arizona. I further attest that the insurance was in effect for the period in which mileage reimbursement has been claimed. I recognize that failure to
comply with state law and Governing Board policy in this regard may result in disciplinary action up to and including dismissal.

I also certify that the travel was accomplished in the performance of official duties; that the information given is true in all
respects and that no claim against the district has before been made for any part thereof, or paid from any other source of funding.

                                                                                                                                                                         ____________
                (Signature of Traveler)                                                                                   (Signature of Authorized Official)               (Date)
Page 6




                                   CLAIMS MUST BEGIN ON "Page 1" OR THEY WILL BE RETURNED.



                                  THE FOLLOWING INFORMATION IS TO BE ITEMIZED ON A DAILY BASIS
                   Private Vehicle Mileage Only   Rnd Private Vehicle Mileage Only
   Date        Departed From          Arrived at   Trip Odometer Reading                                                                           Purpose
                 Location              Location    Y/N           Start             End    Mileage
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                               Miles                -               FINANCIAL SERVICES USE ONLY
                                                                                                                              Received               _____________________
                                                                                                                              Received               _____________________
Date:                                                                                                                         Received               _____________________


In signing this reimbursement claim, I hereby attest that I, the Traveler, have maintained the minimum vehicle insurance levels required by law
in the State of Arizona. I further attest that the insurance was in effect for the period in which mileage reimbursement has been claimed. I recognize that failure to
comply with state law and Governing Board policy in this regard may result in disciplinary action up to and including dismissal.

I also certify that the travel was accomplished in the performance of official duties; that the information given is true in all
respects and that no claim against the district has before been made for any part thereof, or paid from any other source of funding.

                                                                                                                                                                         ____________
                (Signature of Traveler)                                                                                   (Signature of Authorized Official)                (Date)
Page 7




                                   CLAIMS MUST BEGIN ON "Page 1" OR THEY WILL BE RETURNED.



                                  THE FOLLOWING INFORMATION IS TO BE ITEMIZED ON A DAILY BASIS
                   Private Vehicle Mileage Only   Rnd Private Vehicle Mileage Only
   Date        Departed From          Arrived at   Trip Odometer Reading                                                                           Purpose
                 Location              Location    Y/N           Start             End    Mileage
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                               Miles                -               FINANCIAL SERVICES USE ONLY
                                                                                                                              Received               _____________________
                                                                                                                              Received               _____________________
Date:                                                                                                                         Received               _____________________


In signing this reimbursement claim, I hereby attest that I, the Traveler, have maintained the minimum vehicle insurance levels required by law
in the State of Arizona. I further attest that the insurance was in effect for the period in which mileage reimbursement has been claimed. I recognize that failure to
comply with state law and Governing Board policy in this regard may result in disciplinary action up to and including dismissal.

I also certify that the travel was accomplished in the performance of official duties; that the information given is true in all
respects and that no claim against the district has before been made for any part thereof, or paid from any other source of funding.

                                                                                                                                                                         ____________
                (Signature of Traveler)                                                                                   (Signature of Authorized Official)               (Date)
Page 8




                                   CLAIMS MUST BEGIN ON "Page 1" OR THEY WILL BE RETURNED.



                                  THE FOLLOWING INFORMATION IS TO BE ITEMIZED ON A DAILY BASIS
                   Private Vehicle Mileage Only   Rnd Private Vehicle Mileage Only
   Date        Departed From          Arrived at   Trip Odometer Reading                                                                           Purpose
                 Location              Location    Y/N           Start             End    Mileage
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                               Miles                -               FINANCIAL SERVICES USE ONLY
                                                                                                                              Received               _____________________
                                                                                                                              Received               _____________________
Date:                                                                                                                         Received               _____________________


In signing this reimbursement claim, I hereby attest that I, the Traveler, have maintained the minimum vehicle insurance levels required by law
in the State of Arizona. I further attest that the insurance was in effect for the period in which mileage reimbursement has been claimed. I recognize that failure to
comply with state law and Governing Board policy in this regard may result in disciplinary action up to and including dismissal.

I also certify that the travel was accomplished in the performance of official duties; that the information given is true in all
respects and that no claim against the district has before been made for any part thereof, or paid from any other source of funding.

                                                                                                                                                                         ____________
                (Signature of Traveler)                                                                                   (Signature of Authorized Official)               (Date)
Page 9




                                   CLAIMS MUST BEGIN ON "Page 1" OR THEY WILL BE RETURNED.



                                  THE FOLLOWING INFORMATION IS TO BE ITEMIZED ON A DAILY BASIS
                   Private Vehicle Mileage Only   Rnd Private Vehicle Mileage Only
   Date        Departed From          Arrived at   Trip Odometer Reading                                                                           Purpose
                 Location              Location    Y/N           Start             End    Mileage
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                               Miles                -               FINANCIAL SERVICES USE ONLY
                                                                                                                              Received               _____________________
                                                                                                                              Received               _____________________
Date:                                                                                                                         Received               _____________________


In signing this reimbursement claim, I hereby attest that I, the Traveler, have maintained the minimum vehicle insurance levels required by law
in the State of Arizona. I further attest that the insurance was in effect for the period in which mileage reimbursement has been claimed. I recognize that failure to
comply with state law and Governing Board policy in this regard may result in disciplinary action up to and including dismissal.

I also certify that the travel was accomplished in the performance of official duties; that the information given is true in all
respects and that no claim against the district has before been made for any part thereof, or paid from any other source of funding.

                                                                                                                                                                         ____________
                (Signature of Traveler)                                                                                   (Signature of Authorized Official)               (Date)
Page 10




                                   CLAIMS MUST BEGIN ON "Page 1" OR THEY WILL BE RETURNED.



                                  THE FOLLOWING INFORMATION IS TO BE ITEMIZED ON A DAILY BASIS
                   Private Vehicle Mileage Only   Rnd Private Vehicle Mileage Only
   Date        Departed From          Arrived at   Trip Odometer Reading                                                                           Purpose
                 Location              Location    Y/N           Start             End    Mileage
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                               Miles                -               FINANCIAL SERVICES USE ONLY
                                                                                                                              Received               _____________________
                                                                                                                              Received               _____________________
Date:                                                                                                                         Received               _____________________


In signing this reimbursement claim, I hereby attest that I, the Traveler, have maintained the minimum vehicle insurance levels required by law
in the State of Arizona. I further attest that the insurance was in effect for the period in which mileage reimbursement has been claimed. I recognize that failure to
comply with state law and Governing Board policy in this regard may result in disciplinary action up to and including dismissal.

I also certify that the travel was accomplished in the performance of official duties; that the information given is true in all
respects and that no claim against the district has before been made for any part thereof, or paid from any other source of funding.

                                                                                                                                                                         ____________
                (Signature of Traveler)                                                                                   (Signature of Authorized Official)               (Date)
Page 11




                                   CLAIMS MUST BEGIN ON "Page 1" OR THEY WILL BE RETURNED.



                                  THE FOLLOWING INFORMATION IS TO BE ITEMIZED ON A DAILY BASIS
                   Private Vehicle Mileage Only   Rnd Private Vehicle Mileage Only
   Date        Departed From          Arrived at   Trip Odometer Reading                                                                           Purpose
                 Location              Location    Y/N           Start             End    Mileage
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                               Miles                -               FINANCIAL SERVICES USE ONLY
                                                                                                                              Received               _____________________
                                                                                                                              Received               _____________________
Date:                                                                                                                         Received               _____________________


In signing this reimbursement claim, I hereby attest that I, the Traveler, have maintained the minimum vehicle insurance levels required by law
in the State of Arizona. I further attest that the insurance was in effect for the period in which mileage reimbursement has been claimed. I recognize that failure to
comply with state law and Governing Board policy in this regard may result in disciplinary action up to and including dismissal.

I also certify that the travel was accomplished in the performance of official duties; that the information given is true in all
respects and that no claim against the district has before been made for any part thereof, or paid from any other source of funding.

                                                                                                                                                                         ____________
                (Signature of Traveler)                                                                                   (Signature of Authorized Official)               (Date)
Page 12




                                   CLAIMS MUST BEGIN ON "Page 1" OR THEY WILL BE RETURNED.



                                  THE FOLLOWING INFORMATION IS TO BE ITEMIZED ON A DAILY BASIS
                   Private Vehicle Mileage Only   Rnd Private Vehicle Mileage Only
   Date        Departed From          Arrived at   Trip Odometer Reading                                                                           Purpose
                 Location              Location    Y/N           Start             End    Mileage
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                               Miles                -               FINANCIAL SERVICES USE ONLY
                                                                                                                              Received               _____________________
                                                                                                                              Received               _____________________
Date:                                                                                                                         Received               _____________________


In signing this reimbursement claim, I hereby attest that I, the Traveler, have maintained the minimum vehicle insurance levels required by law
in the State of Arizona. I further attest that the insurance was in effect for the period in which mileage reimbursement has been claimed. I recognize that failure to
comply with state law and Governing Board policy in this regard may result in disciplinary action up to and including dismissal.

I also certify that the travel was accomplished in the performance of official duties; that the information given is true in all
respects and that no claim against the district has before been made for any part thereof, or paid from any other source of funding.

                                                                                                                                                                         ____________
                (Signature of Traveler)                                                                                   (Signature of Authorized Official)               (Date)
Page 13




                                   CLAIMS MUST BEGIN ON "Page 1" OR THEY WILL BE RETURNED.



                                  THE FOLLOWING INFORMATION IS TO BE ITEMIZED ON A DAILY BASIS
                   Private Vehicle Mileage Only   Rnd Private Vehicle Mileage Only
   Date        Departed From          Arrived at   Trip Odometer Reading                                                                           Purpose
                 Location              Location    Y/N           Start             End    Mileage
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                               Miles                -               FINANCIAL SERVICES USE ONLY
                                                                                                                              Received               _____________________
                                                                                                                              Received               _____________________
Date:                                                                                                                         Received               _____________________


In signing this reimbursement claim, I hereby attest that I, the Traveler, have maintained the minimum vehicle insurance levels required by law
in the State of Arizona. I further attest that the insurance was in effect for the period in which mileage reimbursement has been claimed. I recognize that failure to
comply with state law and Governing Board policy in this regard may result in disciplinary action up to and including dismissal.

I also certify that the travel was accomplished in the performance of official duties; that the information given is true in all
respects and that no claim against the district has before been made for any part thereof, or paid from any other source of funding.

                                                                                                                                                                         ____________
                (Signature of Traveler)                                                                                   (Signature of Authorized Official)               (Date)
Page 14




                                   CLAIMS MUST BEGIN ON "Page 1" OR THEY WILL BE RETURNED.



                                  THE FOLLOWING INFORMATION IS TO BE ITEMIZED ON A DAILY BASIS
                   Private Vehicle Mileage Only   Rnd Private Vehicle Mileage Only
   Date        Departed From          Arrived at   Trip Odometer Reading                                                                              Purpose
                 Location              Location    Y/N           Start             End    Mileage
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                               Miles                -                  FINANCIAL SERVICES USE ONLY
                                                                                                                                 Received               _____________________
                                                                                                                                 Received               _____________________
Date:                                                                                                                            Received               _____________________


In signing this reimbursement claim, I hereby attest that I, the Traveler, have maintained the minimum vehicle insurance levels required by law
in the State of Arizona. I further attest that the insurance was in effect for the period in which mileage reimbursement has been claimed. I recognize that failure to
comply with state law and Governing Board policy in this regard may result in disciplinary action up to and including dismissal.

I also certify that the travel was accomplished in the performance of official duties; that the information given is true in all
respects and that no claim against the district has before been made for any part thereof, or paid from any other source of funding.


                (Signature of Traveler)                                                                                   (Signature of Authorized Official)    (Date)
S USE ONLY
_____________________
_____________________
_____________________




          ____________
Page 15




                                   CLAIMS MUST BEGIN ON "Page 1" OR THEY WILL BE RETURNED.



                                  THE FOLLOWING INFORMATION IS TO BE ITEMIZED ON A DAILY BASIS
                   Private Vehicle Mileage Only   Rnd Private Vehicle Mileage Only
   Date        Departed From          Arrived at   Trip Odometer Reading                                                                           Purpose
                 Location              Location    Y/N           Start             End    Mileage
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                                                    -
                                                                                               Miles                -               FINANCIAL SERVICES USE ONLY
                                                                                                                              Received               _____________________
                                                                                                                              Received               _____________________
Date:                                                                                                                         Received               _____________________


In signing this reimbursement claim, I hereby attest that I, the Traveler, have maintained the minimum vehicle insurance levels required by law
in the State of Arizona. I further attest that the insurance was in effect for the period in which mileage reimbursement has been claimed. I recognize that failure to
comply with state law and Governing Board policy in this regard may result in disciplinary action up to and including dismissal.

I also certify that the travel was accomplished in the performance of official duties; that the information given is true in all
respects and that no claim against the district has before been made for any part thereof, or paid from any other source of funding.

                                                                                                                                                                         ____________
                (Signature of Traveler)                                                                                   (Signature of Authorized Official)               (Date)

				
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posted:1/31/2012
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