1. REIMBURSEMENT FOR PERSONALLY-OWNED VEHICLE USE

DA 5215

(DA MV 7)

 

STATE OF LOUISIANA

 


REIMBURSEMENT FOR PERSONALLY-OWNED VEHICLE USE

 

PERIOD COVERED:

(complete one)

 

MONTH YEAR                               OR FISCAL YEAR                           --

 

Agency Number

 

Agency Name

 

Total Miles

(Round off to nearest mile)

 

       

       

FISCAL YEAR REPORT ONLY:

 

Number of Employees at or           For fiscal year report only, identify on a separate

above annual breakeven mileage           page individual employees at or above breakeven                     mileage and mileage for which reimbursement was  

                paid to each.

Number of employees below

annual breakeven mileage

 

 

         Signed: ______________________________________________

 

         Title:  

 

         Phone:

 

         Date:   ______________________________________________

 

 

 

DIVISION OF ADMINISTRATION

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