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Month: 1. NAME, ADDRESS, AND VENDOR # OF EMPLOYEE 2. NAME OF BUDGET UNIT: 3. FUND NUMBER: Employee Vendor Number: Employee Name: Employee Address: 4. DEPT PHONE NO.: 5. I HEREBY CERTIFY THAT THE FOLLOWING INFORMATION I HEREBY CERTIFY THAT THE SERVICES DESCRIBED TO MY KNOWLEDGE IS TRUE AND CORRECT. BELOW WERE NECESSARY FOR USE BY THE DEPARTMENT OR DISTRICT. EMPLOYEE SIGNATURE DATE DEPARTMENT HEAD ENDING TOTAL MILES MILEAGE TRAVELED ORGANIZATION OBJECT TOTAL MILEAGE KEY CODE X RATE AMOUNT CLAIMED APPROVED FOR PAYMENT - AUDITOR-CONTROLLER DESCRIPTION DESTINATION & PURPOSE DATE IMPERIAL COUNTY, CALIFORNIA AUDITOR-CONTROLLER'S OFFICE ACCOUNTING SYSTEM IN COUNTY PRIVATE VEHICLE MILEAGE CLAIM STARTING MILEAGE A-C REV 09-18 5. CHECK FOR PICK-UP:
