Iowa Department for the Blind
Time Sheet
MondayTuesdayWednesdayThursdayFridaySaturdaySundayTotal
Date
Beginning Time
Ending Time
Total Hours$ -
Ending Mileage
Beginning Mileage
Destination
Total Miles$ -
IcertifythatIhavedriventheabove_______hourstotransport
_________________________.Mychargeis$______perhour.Mytotal
mileageforthistripis__________,whichistobepaidat$0.39permile.I
understandthatmypaymentsdonothaveanytaxeswithheldandthatIwill
beresponsibleforreportingthemmyself.Thetotalduetomeforthis
service is $________ .
Signature
DriverDate Signed
Printed Name
Street/PO Box #Phone
City/State/Zip