Company Name :

VEHICLE EXPENSES REIMBURSEMENT FORM

I declare that the below vehicle expenses were incurred by me exclusively in the performance of my official duties. MODE OF CONVEYANCE : OWN / COMPANY PROVIDED MILEAGE : DATE Purpose DISTANCE FROM

TO

Kms. Rate AMOUNT Rs.

Total (Rupees : __________________ ) Rate : Rs.4/- per Km for Car running on diesel Rs.7/- per Km for Car running on petrol Rs.2.50/- per KM for 2 wheelers Signature of the claimant: Name of the claimant : Designation : Department : Certification by supervising authority : Yes, the above vehicle expenses were incurred for official purposes

Signature of the approving authority (HOD) Name of the Supervisor :

Signature of the C.E.O.