MILEAGE REIMBURSEMENT

&

EXCESS AUTOMOBILE LIABILITY INSURANCE

VOLUNTEER  CERTIFICATION

RSVP has a mileage reimbursement and additional insurance program for volunteers who drive their own vehicle and keep their auto liability insurance in effect.  Volunteers are reimbursed .25 per mile for mileage from their house to their assigned station and back home.  The maximum reimbursement per month is $30.  Please enter your mileage one way to each station you are assigned:      

·         Station:                                         Odometer start:                        end:                        

·         Station:                                         Odometer start:                        end:                        

·         Station:                                         Odometer start:                        end:                        

The FREE Excess Automobile Liability Insurance provides automobile liability coverage in excess of their own insurance limits while using their vehicle to travel to and from their assignment, or in the course of their volunteer work.  To qualify you must have a valid driver’s license and your own liability insurance.

I, _______________________________, (name of volunteer) do hereby certify that I maintain liability insurance on my own personal vehicle which I drive to and from my place of assignment as a RSVP volunteer through Grant County RSVP.

I understand that I am not entitled to mileage reimbursement or Excess Auto Liability protection as an RSVP volunteer if I do not maintain liability insurance on my own vehicle.  I also understand that my failure to maintain such insurance makes me ineligible to claim reimbursement for my service related volunteer mileage reimbursement.

Signed this ________ day of ______________ 20_____

_____________________________________________

                         Volunteer Signature

Drivers License # ______________________     State _____     Expiration Date:                

_____________________________________________                       Date _____________

                              RSVP Staff