2026 Mileage Reimbursement Form

2026 Mileage Reimbursement Form
Directions:

When filling out the form, please do not hit the "ENTER" button on your keyboard unless you are ready to send the completed form to Lindsey Nichols. In the milage calculation portion: If you are not using the odometer reading, you need to put total trip miles in the odometer end so that it populates in the miles traveled. If you are going to be adding lines throughout the month, please use the SAVE button. The SUBMIT button is for the completed form that will be forwarded for reimbursement.
Employee Name

First NameLast Name
Position/Title
Email Address
example@example.com
Coverage Start Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Coverage End Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Mileage Calculation

Total Mileage
Rate Per Mile ($)
Total Reimbursement ($)
ODOMETER READING columns are to be used only when distance between points cannot be determined by fixed mileage or official highway map.
Pursuant to the provisions and penalties of Chapter 155. Acts 1953, I hereby certify that the foregoing account is just and correct, that the amount claimed is legally due, after allowing all just credits, and that no part of the same has been paid.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

ODOMETER READING columns are to be used only when distance between points cannot be determined by fixed mileage or official highway map.