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FR-1012E-DOC

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					FORM 1012-E
                                            NORTH CAROLINA DEPARTMENT OF TRANSPORTATION
(Rev. 6/02)Front

                                                            PERSONAL CAR EXPENSE
Name                                                  Month                              20                    Base of Operation

   TRIP DATES                                                                                        MILES TRAVELED AT:                          OPTIONAL
 Leave         Return                  FROM                                TO                      Statutory          Motor Pool      Odometer              Purpose
                                                                                                     Rate               Rate
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                                                                                                                                   TOTAL MILES TRAVELED
                   PARKING AND TOLLS (Specify)
 DATE          PARK/         AMOUNT          DATE          PARK/              AMOUNT          $                   $                REIMBURSEMENT RATE PER MILE
               TOLL                                         TOLL
                                                                                              $                   $                REIMBURSEMENT AMOUNT-EACH RATE
                                                                                                           $                       TOTAL MILEAGE REIMBURSEMENT
                                                                                                           $                       TOTAL PARKING AND TOLLS
                                                                                                                                   TOTAL REIMBURSEMENT AMOUNT
                                                                                                           $                       CARRY TO EXPENSE VOUCHER
                                                           TOTAL          $

Statutory [higher] rate applies:                                                                          I CERTIFY THAT THIS IS A TRUE AND ACCURATE STATE-MENT
1. Round trips of 60 miles or less.
                                                                                                          OF PERSONAL CAR MILEAGE INCURRED IN PER-FORMANCE OF
2. Round trips ov er 60 miles when no state car is av ailable at the base of operations or Motor
Fleet
                                                                                                          OFFICIAL BUSINESS FOR THE NORTH CAROLINA DEPARTMENT
   Management Motor Pool. (Attach documentation)                                                  OF TRANSPORTATION.
3. Phy sical handicap request special equipment that is not av ailable on state cars.
4. When use is to the state’s adv antage because of employ ee’s duties.
                                                                                                  ____________________________________________________
Motor Pool [lower] rates applies to:                                                              _
1. Employ ee driv es personal car f or his own c onv enience and 1-4 abov e does not apply .                      EMPLOY EE’S SIGNATURE
2. Any v acation leav e will be taken immediately bef ore, af ter, or during the business trip.

61-03417
(06/02)                                NORTH CAROLINA DEPARTMENT OF TRANSPORTATION
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                                   PERSONAL CAR EXPENSE VOUCHER
NAME OF EMPLOYEE                                            DEPT.          MONTH-YEAR           SS. NO.


JOB TITLE                                                   BASE OF OPERATIONS


EMPLOYEE’S HOME ADDRESS


BOX. NO. OR STREET ADDRESS                                  TOWN AND STATE                                              ZIP


This side to be used only when an employee has no reimbursement claimed other than personal car expense.
Use form 600-EXP for personal car and other travel expenses combined.



Authorized personal car reimbursement amount. Itemized on
reverse.
                                          Less: Travel advance


                      Total reimbursement due me                           Due D.O.T. (Check attached)


Under penalties of perjury I certify this is a true and                I have examined this reimbursement request and certify
accurate statement of my personal car expense incurred in              that it is just, reasonable, necessary and conforms to
the service of the State.                                              State and Department travel policy.


                    EMPLOYEE’S SIGNATURE                                        APPROVING AUTHORITY’S SIGNATURE                TITLE


            COMPLETE THE FOLLOWING                                                    COST DISTRIBUTION
          FOR EMPLOYEES ON TRANSFER                        Dept.    Obj.    Work Order No. Func. CB      Amount   CR   Route   Bridge



   Temporary

   Effective date of transfer

   Permanent

   Old base of operations (Town)

   New base of operations (Town)

   Old home address (Town)

   New home address
   (Town)
   Effective date of transfer




Distance from old Duty Station to new Duty Station:

   35 miles or more             less than 35 miles
  Head of household:    Yes        No


   Date household goods moved, if applicable



                                                                                 TOTAL

                                               RESERVED FOR FISCAL SECTION USE



Return To:                               Audited By:                        Approved By:

				
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