Free Job Search Activity Log—Mileage Reimbursement Request - Nebraska

(R7/08)

Nebraska Workers' Compensation Court JOB SEARCH ACTIVITY LOG - MILEAGE REIMBURSEMENT REQUEST

NAME:

SOCIAL SECURITY #:

Report Period: From:
(Date)

To:
(Date)

TO BE COMPLETED BY EMPLOYEE: Total miles traveled this report period (from back) = Mileage rate Total actual mileage amount X $ $ .585

FOR COURT USE ONLY: Total actual mileage amount $ Maximum weekly amount = 345 miles 345 miles X $ .585 = $201.83 Number of weeks this report period X $201.83 $ REIMBURSEMENT IS LIMITED TO THE LOWEST OF THE TWO AMOUNTS SHOWN ABOVE Total amount to be paid to employee $

Any request for reimbursement exceeding 345 miles per week must include an explanation and be approved by the vocational rehabilitation counselor

Mail my check to:

CHECK HERE IF THIS IS A NEW ADDRESS
I certify that the above information is correct to the best of my knowledge.

(Employee Signature)

(Date)

SUBMIT COMPLETED FORM TO YOUR VOCATIONAL REHABILITATION COUNSELOR FOR VERIFICATION

(Vocational Rehabilitation Counselor Signature)

(Date)

Approved by:

(Court Vocational Rehabilitation Specialist Signature)

(Date)

COMPLETE JOB SEARCH ACTIVITY LOG ON BACK

(R7/08)

COMPLETE THIS LOG FOR EACH EMPLOYER CONTACT WHETHER OR NOT TRAVEL WAS INVOLVED DATE NAME AND ADDRESS OF EMPLOYER CONTACTED RESULTS OF CONTACT (Application, Interview, etc.) MILES TRAVELED

TOTAL NUMBER OF MILES TRAVELED (enter here and on other side of form)