HARRISON COUNTY, TEXAS by XM46j3gN

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									                                          HARRISON COUNTY, TEXAS

                  LOCAL TRANSPORTATION EXPENSE REIMBURSEMENT FORM

NOTE: This form must be completed in detail and submitted along with odometer reading or
documentation of mileage usage (MapQuest, Yahoo, etc. to include starting point and destination
point(s)) to the County Treasurer to claim reimbursement for use of personal auto for official local
county business travel. Reimbursement will be at the current IRS rate.

DATE OF REQUEST:_________________________________

DEPARTMENT:_____________________________________

PERSON SUBMITTING REQUEST:_______________________________________________

           SPEEDOMETER READING TOTAL
DATE           FROM      TO    MILES                           DESCRIPTION OF COUNTY TRAVEL

______         _________        _________       _________      __________________________________
______         _________        _________       _________      __________________________________
______         _________        _________       _________      __________________________________
______         _________        _________       _________      __________________________________
______         _________        _________       _________      __________________________________
______         _________        _________       _________      __________________________________
______         _________        _________       _________      __________________________________
______         _________        _________       _________      __________________________________
______         _________        _________       _________      __________________________________
______         _________        _________       _________      __________________________________
______         _________        _________       _________      __________________________________
______         _________        _________       _________      __________________________________
______         _________        _________       _________      __________________________________
______         _________        _________       _________      __________________________________

TOTAL MILES THIS REPORT-------- _________
LESS: PERSONAL MILES-------------- _________
TOTAL COUNTY MILES--------------- _________ x ____¢ = $________REQUESTED AMT.

“I hereby swear that the above is a true and correct statement of use of my personal auto for official
local county business travel and request reimbursement for the same.”

                                                  _______________________________________
                                                  Signature of Person Making Report

CHARGE TO ACCOUNT NUMBER: _______________________________________

                                                  _______________________________________
                                                  Signature of Supervisor
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FOR COUNTY TREASURER’S USE ONLY

DATE RECEIVED:_____________ DATE ENTERED:_______________
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