Mileage Reimbursement Form
Support Provided by the Mercer County Behavioral Health Commission, Inc.
Driver Name
*
First Name
Last Name
Driver Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Make Check Payable to:
Mailing Address (If Different from Above)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
Email
*
example@example.com
Reporting Agency
*
Community Arts Experience
CYPEN - Zion Education Center
One Kingdom Ministries
Zion Education Center
Reporting Period
*
January
February
March
April
May
June
July
August
September
October
November
December
Hold the Ctrl key down to select multiple dates.
Total Number of Clients
Total Mileage
*
Reimbursement Request Amount $
Mileage will be reimbursed at $0.56 per mile
Supporting Documentation
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Additional Comments
I certify that the above information is accurate. I understand I will only be reimbursed for trips pertaining to programming, ministry, doctor or court-ordered appointments, or other trips approved by the Transportation Coordinator or Recovery Ministry Director, in which I transport Recovery Participants.
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