City of Nashua, New Hampshire
2019 MILEAGE REIMBURSEMENT FORM
(For Mileage Incurred January 1, 2019 through December 31, 2019
Michael
Assessing
Name of Employee Department Name
Please Check
Hold Check for Pickup: x
Purpose of Travet Mail Check
Account to Charge:
32.1.600 Mileage
Accounting Unit Activity
55307 Travel, Local - Mileage Basis
Account Account Category
Date travel was performed Pe MILES FRAVELED
on a weekly basis
{Example: July B thru 15) SUN MON TUES WEDS THURS FRI SAT TOTAL
Assessing Property within City -
4/1/2019 to 1/4/2019 0 0 0 5 9 6 0 20.00
Assessing Property within City :
11712019 to 1/41142019 0 18 6 4 23 9 0 60.00
Assessing Property within City -
4/14/2619 to 1/18/2019 9 0 0 . 42 0 0 O 12 00
Assessing Property within City -
1/21/2019 to 1/25/2108 0 0 10 0 0 20 Q 30 00
Assessing Property wiihin City -
1 28/2019 to 2 1 2019 0 0 12 S 0 5 0 26 00
NOTES:
Total miles traveled 148.00
a) This form must be submitted to the accounts payable
department for reimbursement through Accounts Payabie Rate per mile 0.580
b} The reimbursement rate is .58 cents per mile Total Mileage $ 85.84
(unless otherwise contractually agreed upon).
Tolls 0,000
Total $ $ 85.84
71
A hy leo 19
Date shbmitted Employ€te Signature
el: 4 f
Date approved ¥ Approved by
EFFECTIVE DATE 07/01/2019
\CityFile\Users$\MandileM\My Documents\Mileage 2019\1-19
