For the year ended 2002 2003 2004 2005 2006

Company Name 

Description of Vehicle:  Year  MakeModel

Total number of miles driven during the year. 

Percentage of personal use claimed. 

Was the vehicle used for commuting?  Yes No

If yes to above, what were the commuting miles? 

Was the vehicle available for personal use during off duty hours?  Yes No

Was another vehicle available for personal use?  Yes No

Do adequate records and/or sufficient evidence exist to justify the deduction for business use?  Yes No   If yes, is evidence written?  Yes No

Was the vehicle used by a person who owns 5% or more of the outstanding shares of stock?  Yes No

Was the vehicle used by a relative of such shareholder?  Yes No

Ending Odometer 

Total Mileage 

Business Miles Driven 

Personal Miles Driven 

Percent of Business Use 

I hereby attest that the information above is true and correct to the best of my knowledge. 

Name    Title    Date