Mileage Reimbursement Form PDF Details

If you are in business, you know that tracking your expenses is important. Whether you are self-employed or run a company, it is essential to keep accurate records of all money spent. This includes mileage reimbursement. When travelling for work, you can deduct the cost of getting from one place to another from your taxable income. To do this, you need to submit a mileage reimbursement form. Let's take a look at what this document entails and how to complete it correctly.

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QuestionAnswer
Form NameMileage Reimbursement Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesworkmans comp mileage sheet, worker compensation mileage reimbursement fl, forida workers compensation mileage reimbursement form, mtm florida mileage reimbursement form

Form Preview Example

MILEAGE REIMBURSEMENT FORM

CLAIMANT NAME

SOCIAL SECURITY NUMBER

CLAIMANT ADDRESS

DATE OF ACCIDENT

DATE OF TRAVEL

NAME OF MEDICAL FACILITY

(excluding Pharmacies)

ROUND-TRIP MILEAGE TO & FROM RESIDENCE

I hereby certify and affirm that the above mileage was incurred by me as necessary traveling expenses related ot those medical facility visits pursuant to my workers’ compensation case.

An injured employee or any other party making a claim under Florida Statute 440.105(7) shall provide his or her personal signature attesting that he or she has reviewed, understands, and acknowledges the following statement: “Any person who, knowingly and with intent to injure, defraud, or deceive any employer or employee, insurance company, or self-insured program, files a statement of claim containing any false or misleading information commits insurance fraud, punishable as provided in s. 817.234.” If the injured employee or other party refuses to sign the document attesting that he or she has reviewed, understands, and acknowledges the statement, benefits, or payments under this chapter shall be suspended until such signature is obtained.

Claimant’s Signature

Today’s Date

Watch Mileage Reimbursement Form Video Instruction

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