Free 53553.FH11 - Indiana

RENTAL VEHICLE USE AGREEMENT
State Form 53553 (R2 / 6-08)

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DEPARTMENT OF ADMINISTRATION PROCUREMENT DIVISION 402 West Washington Street, Room W468 Indianapolis, Indiana 46204 Date of request (month, day, year)

INSTRUCTIONS: Form must be typed.
Name of department or agency Telephone number Division Date vehicle to be picked up (month, day, year) Driver's job classification

Account number Date vehicle to be returned (month, day, year)

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Name of driver Address (number, street, city, state and ZIP code) Last four digits of driver's license number Accounting information (fund, center, department, project)

Date of birth (month, day, year)

Approved vehicle class

Location official station Location of vehicle off duty parking lot Distance from home to official station Distance from vehicle off duty parking to official station Distance from home to State Office Building

NOTE: If location of vehicle off duty parking differs from location of official station, a statement of justification is required. Use attachment.
Lease rate from contract Purpose of travel / Destination Number of passengers Type of cargo transported

Vehicle damage (at time of issuance or turn-in) repairs required

User agency agrees to the following: 1. Agency head or designee assumes responsibility for monitoring vehicle use by the assigned driver(s) with regard to compliance with existing state laws, rules, regulations, and guidelines. 2. It is understood by the agency head and assigned driver(s) that this vehicle is NOT to be operated for any personal uses including, but not limited to, commuting or the transporting of other than state employees or agency clients on official business. 3. When not in use on official business (e.g. holidays, weekends, overnight), this vehicle is to be parked adjacent to the driver's official station. Any exception to the parking stipulation must be justified by attachment (e.g. law enforcement personnel on 24-hour duty call). 4. It is understood by the agency head or designee that if the vehicle is being used for out-of-state travel, all necessary approvals have been obtained from IDOA Travel. I do hereby certify that I will abide by the policies and requirements of the Indiana Department of Administration.
Signature of driver Signature of department head requesting vehicle for assignment Signature of agency fiscal Date (month, day, year) Date (month, day, year) Date (month, day, year)

DISTRIBUTION: Original - Agency; Copy - Leasing Company