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Non-State Fuel Card Vehicle Fuel Purchase
This form is for reporting fuel purchases made for a state vehicle not using the state fuel card. For reimbursement of the fuel purchase fill out Finance form FI48 and turn into your agency.
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* Indicates required question
Email
*
Your email
Vehicle # (FO#####) or License plate #
*
Your answer
State fuel card assigned to vehicle (xxxx-x)
*
Your answer
Date of purchase
*
MM
/
DD
/
YYYY
Vehicle mileage
*
Your answer
Vendor name, address, city, state
*
Your answer
Fuel Type
*
Unleaded
Unleaded Plus
Unleaded Super
Diesel
CNG
E85
Gallons purchased
*
Your answer
Price per gallon
*
Your answer
Total amount of purchase
*
Your answer
Reason for not using state fuel card
*
Your answer
Employee name
*
Your answer
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