Commission number Agency Fund / Center Status

REPORT OF VEHICLE MILEAGE AND COSTS Temp Perm

END MILEAGE
State Form 13696 (R2 / 1-97)
Approved by State Board of Accounts 1997 Date in service (month, day, year) Time
START MILEAGE
STATE MOTOR POOL AM PM
Date out of service (month, day, year) Time
MILES DRIVEN
AM PM
1
GASOLINE OIL

DRIVER
MAINTENANCE

INITIAL
ODOMETER DETAIL OF MILES DRIVEN 2
DAY

REASON FOR TRAVEL COMMUTE COSTS

READING COST
MILES GAL. Qts Cost
FROM TO Comm. State Comm. State

Ending Mileage Totals

1
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. I hereby certify that there were no commuting or personal miles driven except as
Pre-Audited and approved by: noted and all other mileage was driven in the discharge of authorized duties.
State agency (signature) Name of agency Division Signature of driver

DISTRIBUTION: White - Motor Pool; Pink - Agency