Vendor Mileage Record Log must be attached to Invoice.

Expense Reports must be TYPED effective 1/1/2016. Hand written forms will be returned.

HBH092023PP1

Invoice #

Agency Name & Hope Behavioral Health & Addictive Disease Wellness Center, 140 Hilda

Address Way, McDonough, GA 30252

Billing

Month/Year Sep-23

Staff Name &

Tiffany Jones 406 Robinson Ave. Albany, Ga.31701

Address County Name HALL

Case Name DOUGLAS PINSON

Tag #'s of all of

SCL1830

all vehicles used

Case Number 18639007

VEHICLE MILEAGE RECORD

Client Name(s) under

DATE

Tag # Services Authorized on SA

(for each Purpose of Full Address REQUIRED TOTAL

vehicle used Trip Odometer Reading Required MILEAGE

for Origin & Destination

MM DD for transport)

Origin Destination

(start point) (end point) Start End

406 ROBINSON AVE 140 Hilda Way,

9 25 SCL1830 HM to McD ALBANY, GA.31701 McDonough, GA 178,364 178,523 159

140 Hilda Way, 406 ROBINSON AVE

9 25 SCL1830 McD to Hm McDonough, GA ALBANY, GA.31701 178,523 178,682 159

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ATTACH CONTINUATION SHEET IF NEEDED Total Mileage 318

Total Mileage Used 318 0.625 per mile $ 198.75

I do solemnly swear, under criminal penalty of a felony for false statements subject to punishment by fine of not more

that $1,000 or by imprisonment of not less than one nor more than five years, that the above statements are true and

I have incurred the described mileage expenses in the discharge of my official duties for the contracted services.

Agency Stamp or Electronic Signature Date Submitted rev. 7.1.22

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