Strong Families Make a Strong Kansas

Mileage log for approved activities and job search

You must have a written Service Authorization from your vocational rehabilitation

counselor in order to receive mileage funds.

                            Name: __________________________________________________

                             Dates covered by this log: ___________________________________



Destination and purpose

Starting address

Ending address

Round trip miles

Turnpike or parking fees


Submit monthly to: ______________________________________________________________________________________________________

             Name and Address of Vocational Rehabilitation Counselor or Contact Person

Use multiple pages if necessary. Your signature is required on each page. Attach turnpike receipts or monthly statements.

Certification: I understand that Rehabilitation Services (RS) will pay only for mileage necessary for approved activities on my Individual Plan for Employment (IPE). RS is not responsible for routine travel for day-to-day activities. I certify that this log is an accurate representation of travel for approved IPE activities and job search. I understand that it is subject to verification. Falsified statements or information will be referred to the Fraud Unit in the Kansas Department for Children and Families.

Signature _________________________________________________________ Date _____________________________________________