Mileage Reimbursement Request

Mileage Reimbursement Request

Boulder Town, Utah
Employee Name*

First NameLast Name
Position/Title*
Email Address*
example@example.com
Phone Number*
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Mileage Calculation -- If you did not record the Odometer Start & End, leave these fields blank and instead use Google Maps to find the milage using the starting and ending addresses. *

	Date (M/D/Y)	Destination	Description/Purpose	Odometer Start	Odometer End	Mileage
1
2
3
4

Total Mileage*
Rate Per Mile ($) -- The state of Utah follows the federal standard mileage rate set by the Internal Revenue Service (IRS). For 2025, the business reimbursement rate is 70 cents per mile.*
Total Reimbursement ($)*
Budget Code -- If you do not know the code or budget line item/department, please describe it as best as you are can (for example: PC, fire department, or training), or leave it blank and communicate with the mayor, chair, or clerks so they can provide the necessary information to complete.
File Upload if applicable

Cancelof
I verify that the above claim is a legal claim and that no part of it has been paid to me previously.
Signature*

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