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DEPT. <br />RFC FUND I DEPT -r—OBJECT <br />k.3 4 -6 7 -11 12 -17 <br />020301 <br />PAY TO: <br />ADDRESS OR <br />DEPARTMENT <br />LOCATION <br />All <br />Types of <br />Mileage <br />2 <br />3 <br />4 <br />Mileage Li <br />CLAIM # <br />1 20 -25 1 28 <br />WARRANT NO. <br />DATE PAID <br />29 -34 <br />1 <br />MC <br />55 <br />1 <br />FIRST NAME <br />35 -48 <br />LAST NAME <br />49 -78 <br />48 - 71 STREET ADDRESS OR DEPARTMENT <br />28 <br />29 - 52 CITY STATE <br />ZIP CODE <br />3 <br />MONTH <br />YEAR <br />PLAN <br />CODE <br />DAYS 'ALLOWANCE OR <br />CLAIMED, PARKING AMT <br />TOTAL <br />MILES <br />4 <br />, <br />1 <br />1 t 1 f I <br />46 <br />AMOUNT <br />29 -38 <br />5 <br />6 <br />7 <br />8 <br />9 <br />10 <br />PLAN A - Straight Mileage <br />Total Number of Miles at . per Mile <br />Actual Cost of Parking (Attach Receipts) <br />LOCAL NON -UNION <br />Total Amount <br />11 <br />12 <br />13 <br />14 <br />15 <br />16 <br />17 <br />18 <br />19 <br />20 <br />21 <br />22 <br />23 <br />PLAN B - Straight Mileage plus $15.00 per Month Basic Allowance <br />Basic Allowance $15.00 <br />Total Number of Miles at . per Mile <br />LOCAL NON -UNION Total Amount' <br />PLAN C - Straight Mileage plus Basic Allowance of $2.00 per day <br />with minimum of $20.00 per month and maximum of $46.00 per month <br />Basic Allowance <br />Total Number of Miles at . per Mile <br />LOCAL <br />NON -UNION Total Amount <br />24 <br />25 <br />26 <br />27 <br />28 <br />29 <br />PLAN D - Monthly Lump Sum Allowance (Amount not to exceed $150.00 per month) <br />Monthly Lump Sum Allowance <br />Less - Working days car not available in excess of <br />5 working days in the month (see back) <br />Total Amount <br />30 <br />31 <br />TOTAL <br />I declare, under the penalties of law, that this claim or demand is just and correct <br />and that no part of it has been paid; and that it is a true and correct statement of <br />the mileage due me for the month of 19 for the use of my automobile <br />on official business as an employee of the County of Ramsey. <br />I also certify that, during the period for which mileage is claimed in the within <br />claim, I had adequate insurance in an amount at least equal to $50,000 - $100,000 <br />for public liability and $10,000 for property damage, and a valid driver's license. <br />APPROVED FOR PAYMENT <br />Supvr. Signature (if applicable) Date <br />Signature of Claimant Date Authorized Signature Date <br />B & A 355 - 02 -81 9:? <br />