Employee Mileage Obligation

EMPLOYEE MILEAGE OBLIGATION

Employer Name:    Employee Name:    Effective Date:

Personal Information

Position Information

Vehicle Information

Mileage Policy Terms

Reimbursement Rate: Employee will be reimbursed for approved business use of a personal vehicle at the rate of per mile (the "Rate"), subject to adjustment by Employer. The Rate applies only to miles driven while performing duties expressly authorized by Employer.

Recordkeeping and Submission: Employee must maintain contemporaneous mileage records identifying date, origin, destination, business purpose and miles for each trip. Employee will submit mileage claims using Employer's required form or system no later than days following the end of each calendar month. Claims submitted after the deadline may be denied in Employer's sole discretion.

Verification and Audit: Employer retains the right to verify reported mileage and supporting documentation. In the event of a verification review, Employee must produce logs, odometer disclosures, and any requested documentation. If Employer determines a mileage claim was materially inaccurate or fraudulent, Employee shall repay any overpayment and may be subject to disciplinary action, up to and including termination.

Overpayments and Withholding: Employee authorizes Employer to offset or withhold amounts owed by Employee to Employer, including overpayments of mileage, from any wages or other payments due to Employee to the extent permitted by law. Employer will provide notice of any intended offset as required by applicable law.

Taxes and Reporting: Reimbursements made under this obligation shall be accounted for and reported in accordance with applicable tax rules. Employee acknowledges that reimbursements contingent on substantiation may be treated differently for tax purposes and agrees to cooperate with Employer's tax reporting requirements.

Insurance and Liability: Employee represents that Vehicle is insured as required by law and will maintain such insurance while using Vehicle for business purposes. Employee agrees that Employer is not responsible for damage to Employee's Vehicle or for injuries to Employee resulting from vehicle use, except to the extent Employer's direct negligence is established under applicable law.

Modification and Termination: Employer may modify or terminate this Mileage Obligation at any time. Any modification will be effective upon written notice to Employee. Termination of employment does not relieve Employee of any repayment obligations arising prior to termination.

Employment History (Most Recent)

Employment History (Previous)

Education

Professional References

Legal Disclosures and Authorizations

At-Will Employment: Nothing in this Mileage Obligation modifies the at-will employment relationship between Employer and Employee, unless a separate written agreement signed by an authorized representative of Employer expressly states otherwise.

Equal Opportunity: Employer is an equal opportunity employer. Decisions regarding assignment of business travel and reimbursement determinations are made without regard to protected status under applicable law.

Authorization to Verify: Employee authorizes Employer to contact prior employers, references, and insurance carriers to verify employment, driving record and insurance coverage as necessary to administer this policy and to obtain information for background checks where permitted by law.

Background Check Consent: I consent to Employer conducting background checks and driving record checks as permitted by law.

Applicant/Employee Certification

I certify that all information provided in this Employee Mileage Obligation is true and complete to the best of my knowledge. I understand that falsification, omission or deceptive statements may result in disciplinary action, including termination. I understand and agree to comply with the recordkeeping, reporting and repayment provisions contained herein.

Authorization to Contact Previous Employers and Insurers: I authorize Employer to contact my previous employers and insurance carriers for the purposes described above.

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