Month:

1. NAME, ADDRESS, AND VENDOR # OF EMPLOYEE 2. NAME OF BUDGET UNIT:

3. FUND NUMBER:Employee Vendor Number:

Employee Name:

Employee Address:

4. DEPT PHONE NO.:

5. I HEREBY CERTIFY THAT THE FOLLOWING INFORMATION I HEREBY CERTIFY THAT THE SERVICES DESCRIBEDTO MY KNOWLEDGE IS TRUE AND CORRECT. BELOW WERE NECESSARY FOR USE BY THE

DEPARTMENT OR DISTRICT.

EMPLOYEE SIGNATURE DATE DEPARTMENT HEADENDING TOTAL MILES

MILEAGE TRAVELED

ORGANIZATION OBJECT TOTAL MILEAGE

KEY CODE X RATE

AMOUNT CLAIMED

APPROVED FOR PAYMENT - AUDITOR-CONTROLLER

DESCRIPTION

DESTINATION & PURPOSEDATE

IMPERIAL COUNTY, CALIFORNIAAUDITOR-CONTROLLER'S OFFICE ACCOUNTING SYSTEMIN COUNTY PRIVATE VEHICLE MILEAGE CLAIM

STARTINGMILEAGE

A-C REV 09-18

5. CHECK FOR PICK-UP: