HHSA - DSS - WTW 576 Mileage Claim Form

Total Claimed
First 500
500+
Adjustment miles for a transportation advance or transportation overpayment
Total miles claimed after adjustments for advances
Total miles blank_miles X .655 cents per mile for first 500 miles, .28 per mile after 500 (IRS rate as of 1/1/21) = $ blank_total
Signature of Welfare to Work Participant*
Date*

MonthDayYear
Date
WTW SW Approval Signature
Date

MonthDayYear
Should be Empty:

Welfare to Work Mileage Claim Form