Summer In Home Care LLC.

MONTHLY MILEAGE REPORT

EMPLOYEE (PRINT): Kassaye, Bethlehem Date Due: ______11/30/2022____________

Date Name &Address of Destination Odometer Start Odometer End Purpose Miles Driven Client’s Initials
Example Ex. Safeway Ex. 82683 Ex. 82689 Ex. Shopping Ex.6 miles Ex. CL
8/08/200 123 4th Ave. S. Seattle, WA 98104
7

CLIENT (PRINT): Hagstrom, Patricia Office: __ Seattle

*YOUR MAXIMUM MILEAGE ALLOWED PER MONTH FOR THIS CLIENT IS _100______.
TOTAL MILES DRIVEN: ____________
By signing below, I acknowledge that the information above is authentic and reflects accurate mileage driven by me for transportation tasks as authorized in my
client’s CARE plan. I understand and agree that failure to record accurate information is gross misconduct and subject to disciplinary action.

______________________________________ _______________________________________
EMPLOYEE SIGNATURE CLIENT SIGNATURE

________Meklit ____________________________________________________
SUPERVISOR NAME SUPERVISOR SIGNATURE