Mileage Claim Form

Montreal Presbytery

When doing work on behalf of the Montreal Presbytery please submit this form on a quarterly basis to the chair of your Committee for reimbursement.

 

Name:__________________________________
                            (please print)

Date _______________

 

Name of Committee ___________________________

 

Nature of the work ___________________________________________

                           ___________________________________________

___________________________________________

 

from___________ to____________ km ____ rate @___ km = $____
from___________ to____________ km ____ rate @___ km = $____
from___________ to____________ km ____ rate @___ km = $____
from___________ to____________ km ____ rate @___ km = $____
from___________ to____________ km ____ rate @___ km = $____
from___________ to____________ km ____ rate @___ km = $____

                                                            Total ____ km                 Total $____

total travel amount requested $__________ telephone costs $_________

Address (to mail cheque) _____________________________

 

email: ____________________ ph no. ________________

Home Pastoral Charge: ____________________________

 

________________________________

Signature

_______________________________

Signature of committee chair