Mileage Reimbursement Form Template (For Employees)

If your employer reimburses business mileage but does not provide a standard form, this template covers the four IRS-required fields plus the typical employer-side data needs. Adapt for your situation; have your employer review for accountable-plan compliance before adopting.

Why a standard form helps

A clean, repeatable submission form makes it easier for your employer to approve reimbursement quickly. It also builds your audit-defensible mileage record over time. Employers running an accountable plan need substantiation including date, destination, business purpose, and miles for every trip.

Template form structure

Header section:

• Employee name
• Employee ID or department
• Submission month and year
• Date submitted

Per-trip rows (one row each):

• Date
• Starting location (general; address optional)
• Destination (specific address or client name)
• Business purpose (one-line description)
• Miles driven (round trip if applicable)
• Reimbursement at IRS rate (miles × 72.5¢)

Footer section:

• Total miles for the month
• Total reimbursement requested
• Employee signature and date
• Approver name (manager) and date

How to use it

1. Print or share the template with your employer's HR or accounting team for adoption.
2. Track miles in a tracker app throughout the month.
3. On the 1st of the next month, export the trip log and transfer entries to the form.
4. Submit to your manager for approval and reimbursement.
5. Keep your own copy plus the original tracker log for at least 7 years.

Why the form alone is not enough

A reimbursement form is the SUBMISSION instrument. The underlying mileage log (with all four IRS fields, contemporaneous timestamps, and route detail) is the audit evidence. The form pulls FROM the log; it does not replace it. Keep the log separately, ideally as auto-tracked records from a mileage app.

Mandate-state employees

If you are in a mandate state (CA, IL, MA, NY, WA, NH, ND, MT, IA), having a standardized monthly form helps document that your employer is or is not meeting their statutory reimbursement obligation. Save every submitted form. State-by-state reimbursement laws.

If your employer does not have a reimbursement program

Federal W-2 mileage deduction was eliminated by OBBBA in 2025. More on what that means. If you are in a mandate state and your employer does not reimburse, file a wage claim with your state's Department of Labor.

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