Form MFOMS-17 "State Motor Vehicle Commute Charge" - Maryland

What Is Form MFOMS-17?

This is a legal form that was released by the Maryland Department of Budget and Management - 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 March 1, 2019;
  • The latest edition provided by the Maryland Department of Budget and Management;
  • 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 fillable version of Form MFOMS-17 by clicking the link below or browse more documents and templates provided by the Maryland Department of Budget and Management.

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Download Form MFOMS-17 "State Motor Vehicle Commute Charge" - Maryland

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MFOMS-17
STATE MOTOR VEHICLE COMMUTE CHARGE
(Revised 3/2019)
Agency Name:
Agency Appropriation Code:
State Vehicle License Plate #:
State Vehicle VIN#:
State Vehicle Type (Sedan, Van, Pickup, SUV, etc…):
Assigned Driver:
Phone Number:
___________________________
_______________________________________________________________________
Driver’s Preferred Phone Number
Last name
First name
M.I.
Assigned Driver’s Title and Office/Unit Name:
Social Security #:
Driver’s Home Address:
Street
Unit/Apt. #
City
State
Zip Code
Driver’s State Office Address:
Street
Room/Suite #
City
State
Zip Code
Address at which the vehicle will be parked overnight:
Street
Unit/Apt. #
City
State
Zip Code
Purpose Code (Choose One):
1. Initiate Commute Charge for this Authorized Driver.
2. Cancel Commute Charge for this Authorized Driver.
3. Change Commute Charge for this Authorized Driver, i.e. change in commute miles, change in vehicle type.
BiWeekly Deduction Amount: $
Round-Trip Commute Miles (attach map):
Please read the following statement before completing this form. I solemnly declare under penalty of
perjury that to the best of my knowledge, information and belief, the contents of this form are true. I agree
to make proper notification to the Department of Budget & Management in the event of any change, which
affects the accuracy of this form.
ASSIGNED DRIVER SIGNATURE
Print Name
DATE
FLEET MANAGER’S AUTHORIZATION
Print Name
DATE
DEPARTMENT/AGENCY HEAD AUTHORIZATION
Print Name
DATE
DEPARTMENT OF BUDGET & MANAGEMENT APPROVAL
DATE
* An original of this form is to be forwarded to the State Fleet Administration Unit for processing.
**Attach a map (such as GoogleMaps with the route shown) depicting the driver’s work and home addresses.
MFOMS-17
STATE MOTOR VEHICLE COMMUTE CHARGE
(Revised 3/2019)
Agency Name:
Agency Appropriation Code:
State Vehicle License Plate #:
State Vehicle VIN#:
State Vehicle Type (Sedan, Van, Pickup, SUV, etc…):
Assigned Driver:
Phone Number:
___________________________
_______________________________________________________________________
Driver’s Preferred Phone Number
Last name
First name
M.I.
Assigned Driver’s Title and Office/Unit Name:
Social Security #:
Driver’s Home Address:
Street
Unit/Apt. #
City
State
Zip Code
Driver’s State Office Address:
Street
Room/Suite #
City
State
Zip Code
Address at which the vehicle will be parked overnight:
Street
Unit/Apt. #
City
State
Zip Code
Purpose Code (Choose One):
1. Initiate Commute Charge for this Authorized Driver.
2. Cancel Commute Charge for this Authorized Driver.
3. Change Commute Charge for this Authorized Driver, i.e. change in commute miles, change in vehicle type.
BiWeekly Deduction Amount: $
Round-Trip Commute Miles (attach map):
Please read the following statement before completing this form. I solemnly declare under penalty of
perjury that to the best of my knowledge, information and belief, the contents of this form are true. I agree
to make proper notification to the Department of Budget & Management in the event of any change, which
affects the accuracy of this form.
ASSIGNED DRIVER SIGNATURE
Print Name
DATE
FLEET MANAGER’S AUTHORIZATION
Print Name
DATE
DEPARTMENT/AGENCY HEAD AUTHORIZATION
Print Name
DATE
DEPARTMENT OF BUDGET & MANAGEMENT APPROVAL
DATE
* An original of this form is to be forwarded to the State Fleet Administration Unit for processing.
**Attach a map (such as GoogleMaps with the route shown) depicting the driver’s work and home addresses.