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