Automobile Use Form



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Date05.05.2018
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Automobile Use Form



Complete a Separate Form for Each Automobile:


Name:

     

PS EmplId (or SSN) :

     

Automobile Make:

     

Model:

     

Beginning Odometer:

     

Ending Odometer:

     

Total Mileage:

     

Auto Color/Options:

     



A

B

C

Date of Use

Number of Miles Driven

Personal

Number of Miles Driven

Business*

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     










**Total:

     

     

*Miles driven to/from work are considered personal miles; not business miles.



**Please make sure your total personal and business miles equal the total mileage calculated above.


Signature:




Date Submitted:





Rev 11/13


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