Free Mileage Reimbursement Form for VR Providers - Massachusetts

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