Mileage Form

See the Mileage Distance Chart

Mileage reimbursement (rate and allowable miles) will be calculated per LCSSU mileage policy in employee handbook.

Reimbursement checks are processed monthly. If you wish to receive reimbursement by the 20th of the month, this form must be completed and signed by the Program Supervisor and the Director by the 15th of the month.

Mileage

Month *

Year *

---

Date *

Trip (from/to) or Purpose *

Odometer In

Odometer Out

Net Miles *

Milage

Date *

Trip (from/to) or Purpose *

Odometer In

Odometer Out

Net Miles *

Add Remove

Total Miles *

Employee's Signature:

Program Supervisor's Signature:

Director's Signature:

Please print this form and get required signatures.

PRINT FORM