Mileage Reimbursement Form
Once approved by your supervisor, mileage reimbursements will be included on your paycheck. The IRS update the mileage reimbursement rate annually. Once you enter in each trip's mileage, the form will automatically calculate your total mileage and reimbursement.
Employee Name
*
First Name
Last Name
Email
*
example@example.com
Mileage Calculation
*
Rows
Date (M/D/Y)
Destination
Description/Purpose
Mileage
For Which LASER Site?
1
2
3
4
5
6
7
8
9
10
2026 Mileage Reimbursement Rate ($0.72 per mile)
Total Mileage
*
Total Reimbursement ($)
*
Submit
DIRECTOR APPROVAL
Name of Director Approving Mileage Reimbursement
First Name
Last Name
Date of Approval
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Should be Empty: