Employee Mileage Reimbursement by ace20238

VIEWS: 70 PAGES: 1

More Info
									                                                   Bi-Weekly Mileage Reimbursement Form
Employee:                                                                 Employee ID #:                                      License Plate #:
Pay Period:                                                                                                                     Odometer Readings
               Case Name or Name of
    Date             Contact                       Starting Address           Destination Address           Trip Purpose      Start of Trip End of Trip Trip Miles
                                                                                                                                                                  0
                                                                                                                                                                  0
                                                                                                                                                                  0
                                                                                                                                                                  0
                                                                                                                                                                  0
                                                                                                                                                                  0
                                                                                                                                                                  0
                                                                                                                                                                  0
                                                                                                                                                                  0
                                                                                                                                                                  0
                                                                                                                                                                  0
                                                                                                                                                                  0
                                                                                                                                                                  0
                                                                                                                                                                  0
                                                                                                                                                                  0
                                                                                                                                                                  0
                                                                                                                                                                  0
                                                                                                                                                                  0
                                                                                                                                                                  0
                                                                                                                                                                  0
                                                                                                                                                                  0
                                                                                                                                                                  0
                                                                                                                                                                  0
                                                                                                                                                                  0
                                                                                                                                                                  0
                                                                                                                                                                  0
                                                                                                                                                                  0
                                                                                                                                                                  0
                                                                                                                                                                  0
                                                                                                                                                                  0
                                                                                                                                                                  0
                                                                                                                                                                  0
                                                                                                                                                                  0
                                                                                                                                                                  0
                                                                                                                                                                  0
                                                                                                                                                                  0
                                                                                                                                                                  0
                                                                                                                                                                  0
                                                                                                                                                                  0
                                                                                                                                                                  0
                                                                                                                                            Total Miles           0
Instructions
1. Complete within 5 work days of the end of the bi-weekly payroll period. If the employee fails to do so, the Appointing Authority, at their
discretion, may deny reimbursement.
2. Complete one line of this card for each trip.
3. Begin each bi-weekly pay period with a new sheet.
4. Summarize bi-weekly mileage by dates and totals on a separate sheet.
5. Supervisor must enter mileage into Kronos by the end of the pay period.
6. Mileage form must be sent to HR no later than the Monday following the end of the pay period.


EMPLOYEE CERTIFICATION: I hereby certify that the foregoing statements are true and correct, and such reported mileage represents actual
mileage driven in my privately owned automobile while in performance of my official duties as an employee of Denver Human Services. I also
certify that I remain in compliance with the insurance and drivers license requirements in Fiscal Accountability Rule 2.9 – Use of Personal
Vehicles for City Business.
       Sign:                                                                                                          Date:

SUPERVISOR’S CERTIFICATION: The travel to the destinations listed was necessary for the performance of the official duty of this employee.
No mileage claimed herein could have been avoided through use of motor center vehicles.
       Sign:                                                                                                          Date:

								
To top