Massachusetts > Workers Comp
Mileage Voucher - Massachusetts
| Mileage Voucher Form. This is a Massachusetts form and can be used in Workers Comp . |
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THE COMMONWEALTH OF MASSACHUSETTS Department of Industrial Accidents 600 Washington Street, 7th Floor Boston, Massachusetts 02111 DEVAL L. PATRICK Governor TIMOTHY P. MURRAY Lieutenant Governor PAUL V. BUCKLEY Commissioner Office of General Counsel Workers' Compensation Trust Fund Mileage Voucher Note: tolls/lunches/car maintenance are not allowed Authorized signature the person with whom the meeting occurred, e.g. health provider, client, instructor, etc. Certified Provider Name of Employee D/A Board # Odometer Begin and End Name of Employer Date Prepared Authorized Signature Destination/Explanation Date Mileage Total Total Miles Instructions Fill in all columns as indicated Last column authorized signature required from the person from whom the service was received I hereby certify under penalty of perjury that the above amounts ass itemized are true and correct, were incurred by me during necessary travel. I hereby certify that this travel was necessary and authorized. Signed____________________________ Traveler ____________________ Approving Authority ______ Date Tel. # (617) 727-4900 - www.mass.gov/dia American LegalNet, Inc. www.FormsWorkflow.com
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