MILEAGE & PARKING REIMBURSEMENT REQUEST: EMPLOYEES

Hennepin County, Minnesota

HC 489A (12/06) D 123099
DEPARTMENT/DIVISION DATE EMPLOYEE NUMBER WARRANT NO.

12/30/99
NAME - FIRST M.I. LAST MAIL CODE NO. OF MILES BETWEEN
HOME & WORK

COUNTY ADDRESS

EARNING
By signing below, claimant attests to the S PROJECT PROJECT
following: ID AMOUNT FUND ACCOUNT CENTER COMPANY NUMBER
1) I have a valid driver's license and motor vehicle
insurance as required by law.
2) Per Minnesota Statute 471.391, Subd. 1: I 165 52331
declare under the penalties of law that this claim is just
and correct and that no part of it has been paid.
166 52333
____________________________________________
______ This claim can be paid only if completely itemized. All required
TOTAL information must be carefully filled in. See instructions.
SIGNATURE OF CLAIMANT (Use blue ink) BUS /
NUMBER TRAIN PARKING
DATE FROM TO OF MILES FARE EXPENSE

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HC 489A (12/06) D 123099
DEPARTMENT/DIVISION DATE EMPLOYEE NUMBER WARRANT NO.

12/30/99
NAME - FIRST M.I. LAST MAIL CODE NO. OF MILES BETWEEN
HOME & WORK

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CURRENT Effective Date Rate Effective Date Rate TOTAL

RATE PER MILEAGE
NUMBER
MILEAGE RATES: 1/1/2009 0.55 1/1/2010 0.50 OF MILES
MILE EXPENSE

If you have Parking Reimbursement

Status at the Monthly Contract Rate(1), CONTRACT MONTH PREVIOUS MILEAGE RATE
enter at right the parking contract month
and amount up to the monthly maximum. CONTRACT AMOUNT CURRENT MILEAGE RATE
APPROVED BY DEPARTMENT HEAD/DESIGNEE: DATE: TOTAL MILEAGE EXPENSES
TOTAL BUS/TRAIN FARES $0.00
TOTAL PARKING EXPENSES (1) $0.00
AUDITED BY: DATE: MONTHLY PARKING CONTRACT (2) $0.00
TOTAL EXPENSES $0.00

(1) See the Automobile Required policy in the HC Administrative Manual. Attach required receipts.
(2) Monthly contract applies only to employees that have Parking Reimbursement Status at the Monthly Contract Rate.

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