Free Post-Secondary Training Mileage Reimbursement Request - Nebraska

(R4/09)

Nebraska Workers' Compensation Court POST-SECONDARY TRAINING MILEAGE REIMBURSEMENT REQUEST
(TO BE COMPLETED MONTHLY)

NAME:

SOCIAL SECURITY #:

Report Period: From:
(Date)

To:
(Date)

I am regularly scheduled to attend training TO BE COMPLETED BY EMPLOYEE: Total miles traveled this report period (from back) = Mileage rate Total actual mileage amount X $ $ .55

days per week at
(Name of Training Facility)

FOR COURT USE ONLY: Total actual mileage amount $ Training provider room and board rate (if applicable) $ Maximum monthly amount when no room and board available $ REIMBURSEMENT IS LIMITED TO THE LOWEST OF THE THREE 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)

COMPLETE MILEAGE LOG ON BACK

(R4/09)

DATE

COMPLETE THIS LOG FOR EACH TRAINING TRIP LOCATION LOCATION REASON (For example: class, TRAVELED FROM TRAVELED TO job site, tutor, etc.)

NUMBER OF MILES

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