Form MDH4641 "Fuel Purchases Made Outside the State's Fuel Management Systems Report" - Maryland

What Is Form MDH4641?

This is a legal form that was released by the Maryland Department of Health - a government authority operating within Maryland. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2004;
  • The latest edition provided by the Maryland Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form MDH4641 by clicking the link below or browse more documents and templates provided by the Maryland Department of Health.

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Download Form MDH4641 "Fuel Purchases Made Outside the State's Fuel Management Systems Report" - Maryland

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MARYLAND DEPARTMENT OF HEALTH
CENTRAL SERVICES DIVISION
201 W. Preston Street, Baltimore, Maryland 21201
REPORT
FUEL PURCHASES MADE OUTSIDE THE STATE’S FUEL MANAGEMENT SYSTEMS
Drivers Name:
Date:
Office/Unit:
Phone #:
Vehicle Tag #:
Reimbursement Amount $
Acknowledgement:
I am aware that it is my responsibility as a driver of a State-owned vehicle to ensure that all required documents are with
the vehicle prior to operation. I am also aware that “State vehicles should obtain gasoline/oil from the Statewide
Automated Fuel Dispensing and Management System except for emergencies or rare unusual instances when such use is
not possible” (Ref: State Vehicle Fleet Policies and Procedures para. 12.01, July 2002).
Briefly describe reasons for reimbursement: (Attach copy of fuel/oil receipts to this letter)
The driver certifies he/she has read and understands the General Rules for Drivers of State Vehicles.
Driver’s Signature:
Date:
Office/Unit Head Authorization Approval:
Date:
Fleet Management concur/nonconcur:
Date:
Note: An Expense Report or Disbursement of Petty Cash Report and Fuel/Oil Receipts must be attached
to this report prior to submission to accounting.
MDH# 4641 2/2004
MARYLAND DEPARTMENT OF HEALTH
CENTRAL SERVICES DIVISION
201 W. Preston Street, Baltimore, Maryland 21201
REPORT
FUEL PURCHASES MADE OUTSIDE THE STATE’S FUEL MANAGEMENT SYSTEMS
Drivers Name:
Date:
Office/Unit:
Phone #:
Vehicle Tag #:
Reimbursement Amount $
Acknowledgement:
I am aware that it is my responsibility as a driver of a State-owned vehicle to ensure that all required documents are with
the vehicle prior to operation. I am also aware that “State vehicles should obtain gasoline/oil from the Statewide
Automated Fuel Dispensing and Management System except for emergencies or rare unusual instances when such use is
not possible” (Ref: State Vehicle Fleet Policies and Procedures para. 12.01, July 2002).
Briefly describe reasons for reimbursement: (Attach copy of fuel/oil receipts to this letter)
The driver certifies he/she has read and understands the General Rules for Drivers of State Vehicles.
Driver’s Signature:
Date:
Office/Unit Head Authorization Approval:
Date:
Fleet Management concur/nonconcur:
Date:
Note: An Expense Report or Disbursement of Petty Cash Report and Fuel/Oil Receipts must be attached
to this report prior to submission to accounting.
MDH# 4641 2/2004