Mileage Voucher

Office of General Counsel Workers222 Compensation Trust Fund Mileage Voucher Note: Tolls/lunches/car maintenance are not allowed Authorized Signature 226 the person with whom the meeting occurred, e.g. health care provider, client, instructor, etc. Certified Provider Name of Employee DI A Board # Name of Employer Date Prepared Authorized Signature Date Destination/Expla nation Odometer Begin and Mileage Total Total Miles Instructions 226 Fill in all columns at indicated. Last Column 226 authorized signature required from the person whom the service was received. I hereby certify under the penalty of perjury I hereby certify that this travel that the above amounts as itemized are was necessary and authorized. true and correct, were incurred by me during necessary travel. Signed Traveler Approving Authority Date American LegalNet, Inc. www.FormsWorkFlow.com