State of Louisiana, Division of Administration Form Required for Reimbursement for Mileage When Using Personally-Owned Vehicle for Official College Business
DA 5215 (DA MV 7) STATE OF LOUISIANA REIMBURSEMENT FOR PERSONALLY-OWNED VEHICLE USE PERIOD COVERED: (complete one) MONTH YEAR OR FISCAL YEAR -- 3 5 6 4 1 3 0 5 41 Agency Number DELGADO COMMUNITY COLLEGE 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
Allowed
Microsoft Office Word (.doc, .dot) - application/msword
DELGADO FORMS 
