Free GED, ESL, ABE Training Mileage Reimbursement Request - Nebraska

(R4/09)

Nebraska Workers' Compensation Court TRAINING MILEAGE REIMBURSEMENT REQUEST

GED
NAME:

ESL

ABE

OTHER

(TO BE COMPLETED MONTHLY)

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 $ $ .55

FOR COURT USE ONLY: Total actual mileage amount $

Maximum monthly amount $ REIMBURSEMENT IS LIMITED TO THE LOWEST OF THE TWO AMOUNTS SHOWN ABOVE Total amount to be paid to employee $

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)

ATTACH COMPLETED ATTENDANCE LOG