DISTANCE TEST:

DISTANCE 1 (Old residence to old place of work)	=	_______ miles
DISTANCE 2 (Old residence to new place of work)	=	_______ miles
DISTANCE 3 (Subtract Distance 1 from Distance 2)	=	_______ miles
		(if 50 miles or more, Distance Test satisfied)

	3210/3220	3240	3250	3260	3260	3280		Office Use only
RECEIPT DATE	AIR	LODGING	MEALS	LOCAL TRAVEL	MILEAGE / FUEL	MISC	TOTALS	TAXABLE	NON-TAX
1
2
3
4
5
6
7
8
9
10
11
12
TOTALS

Employee Signature    ________________________________________

Dept. Head Approval    ________________________________________

• List each receipt on a separate line. If additional lines are needed, please use additional forms. These forms are available in Accounts Payable.
• Travel by car: you may be reimbursed for actual expenses such as fuel, oil, tolls, etc., or you may be reimbursed as the current IRS mileage rate.
• If you choose to use the mileage rate only 10 cents/mile is non-taxable.

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