LENAPE REGIONAL HIGH SCHOOL DISTRICT
REIMBURSEMENT FORM Mileage and Expense
Insert Name Here Mileage Date
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
Purchase Order Number
Destination
Regular Miles
Reimbursable Miles
Total Reimbursable Miles $ x $ $ Reimbursable Expenditures
0.445 -
Total Reimbursable Expenditures Certification Total Reimbursement $
-
I read the New Jersey travel reimbursement guidelines as established by the Department of Treasury in NJOMB circular letter 06-02 as well as the NJOMB circular A-87 and made every reasonable effort to comply with all NJOMB Regulations. I attest that any costs that are not in compliance with the New Jersey travel guidelines are directly related to and within the scope of my current work responsibilities; are caused by or subject to contractual provisions, other statutory requirements or federal regulatory requirements; and are deemed necessary or unavoidable. I do solemnly declare and certify under the penalties of the law that the above expenses are correct in all its particulars.
Employee Signature Date of Request
The Lenape Regional High School District reserves the right to have reimbursement put on hold until all documentation is received in the manner specified. Travel reimbursement will be paid only upon compliance with the board’s policy provisions and approval requirements.