Instructions for completing pdf on line
INDIVIDUAL VEHICLE DISTANCE AND FUEL REPORT
(Must be kept by driver for each trip)
License Year _________
The Individual Vehicle Distance Record and Fuel Report must account for all distance traveled and all fuel received. 2. If you use a substitute vehicle, prepare a separate Individual Vehicle Distance and Fuel Report to account for the distance traveled and fuel received by the substitute vehicle. Driver's Name (Printed) Driver's Signature Account Number Registrant Name (Printed) Address
Fleet Number Vehicle Identification Number (VIN) Trip Origin
City: ______________________Jurisdiction: ______ City: ______________________Jurisdiction: ______ Start Date End Date Fuel Type Rate Per Trip _____ _____ _____ _____ _____ _____ Distance Per Gallon Mo. Day Yr. Mo. Day Yr. Diesel ______ Gasoline ______ Other ______ (5) Show Odometer Reading: a. At beginning of Trip b. When Exiting Jurisdiction c. At End of Trip (6) Jurisdiction Distance Traveled (7) Name and Address (City &State) of Fuel Stop (8) Fuel Purchased Gallons/Liters (9) Fuel Invoice Number
(3) Date Mo./Day/Yr.
(4) Highway or Route Traveled
1 2 3 4 5 6 7 8
End Odometer ___________ Beginning Odometer ______________ TOTAL Distance ___________
Total Trip Distance
0 __________ 0
This form must be kept by the driver. Each item must be completed. Enter name of jurisdiction in which trip begins on Line 1, Column 2. Enter odometer reading at beginning of trip on Line 1, Column 5. Record name of next jurisdiction entered and odometer reading on Line 2, Column 2 and 5, etc. Record distance traveled in each jurisdiction in Column 6. The difference between the "end odometer" reading in Column 5 should agree with total trip distance recorded in Column 6. If hubodometer distance is used enter in Column 5, and indicate with "'HUB".
THIS FORM MAY BE REPRODUCED