Mileage and meal reimbursement form, direct deposit form and sample documents

We have placed forms below that are necessary to receive reimbursement for mileage and meal expenses that are authorized under the State and Local Implementation Grant Program (SLIGP). Government and Privately Owned Vehicle (POV) reimbursement rates are different thus requiring different reimbursement forms. POV mileage and meals can be documented for reimbursement on the same form however Government mileage and meal reimbursement will require separate forms unless the total of the reimbursed amount is to be paid to your agency. Examples of how to complete these forms are below as well.

Reimbursement to individuals will be through direct deposit into your banking account. To facilitate that process the ACH_W9_Fillable form, below, needs to be completed. The Example ACH_W9 form shows the yellow highlighted areas on the form to be completed. Please note the requirement of a copy of your check with routing and account numbers or a letter from your financial institution with those numbers provided.

If you have questions or a scenario that isn’t covered above, please email or contact Wilhelm at 402.471.7973. Once completed you may scan, attach and send the documents by email to: Bob.Wilhelm@nebraska.gov or mail them in care of Wilhelm to Office of the CIO P.O. Box 95045, Lincoln, NE 68509-5045.

• EXPENSE REIMBURSEMENT REQUEST - Vehicle Mileage (Excel)


• EXPENSE REIMBURSEMENT REQUEST - POV Mileage (Excel)


• Sample GOV Vehicle Mileage reimbursement form (PDF)


• Sample POV mileage reimbursement (PDF)


• Example ACH W9 form (PDF)


• ACH ENROLLMENT FORM (PDF)

 

 

Please Contact:

BobWilhelm
State and Local Implementation Grant Program Project Manager
Nebraska Office of the CIO
 402.471.7973
 Bob.Wilhelm@Nebraska.gov