Free 13696.FH11 - Indiana

REPORT OF VEHICLE MILEAGE AND COSTS
State Form 13696 (R2 / 1-97) Approved by State Board of Accounts 1997 STATE MOTOR POOL

Commission number

Agency Fund / Center Time

Status Temp Perm PM PM

END MILEAGE START MILEAGE MILES DRIVEN

Date in service (month, day, year) Date out of service (month, day, year)
1

AM Time AM

ODOMETER READING

DAY

DETAIL OF MILES DRIVEN FROM TO

REASON FOR TRAVEL

COMMUTE MILES

2

GAL.

GASOLINE COST Comm. State

Qts

Cost

MAINTENANCE COSTS Comm. State

Pre-Audited and approved by: State agency (signature)

Totals Ending Mileage For temporary vehicles, show each individual trip including address for each location. For permanent vehicles, record trips in accordance with your agency's policies. 2 Must include number of personal miles.
1

I hereby certify that there were no commuting or personal miles driven except as noted and all other mileage was driven in the discharge of authorized duties.
Signature of driver

Name of agency

Division

DISTRIBUTION: White - Motor Pool; Pink - Agency

DRIVER INITIAL

OIL