LMV VOLUNTEER PILOT REPORT & CLAIM FOR REIMBURSEMENT

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**LMV Form 10**

Fill out one full report for each trip conducted. 
LMV Village & Clinic Report (LMV Form 1B) is also required.

Submit by email to:
LMV corporate vice chairman
Sponsoring chapter president
Sponsoring chapter vice-pres	
Sponsoring chapter treasurer
LMV corporate chief pilot	
LMV executive director

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Volunteer Pilot Name:
Volunteer Pilot Chapter:
A/C Type:
N#:
BFR Due:
Medical Due:

Trip Start Date (mm/dd/yy):
Trip End Date (mm/dd/yy):

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**Flight Occupants**

Include yourself. For each, indicate Name, Chapter, Volunteer Skill, and Trip Fee Collected (amount in USD), if any.

1. 
2. 
3. 
4. 
5. 
6. 

Total # of Occupants:
Total Trip Fees Collected, in USD: $

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**Aircraft Expenses**

Rental Rate ($/Hr.):	$
Hours Flown:

Subtotal: $   

Fuel:
Oil: 
Airport Expenditures: 

Total Expenses (in USD): $

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**Cost-Sharing Reimbursement Check Name and Address**

Enter address below to which LMV should send your check.

Name:
Address:
City, State, Zip:

Make check payable to:

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**Volunteer Pilot Cost Sharing Reimbursement Maximum**

Volunteer pilot cost sharing reimbursement by LMV shall reimburse pilots for direct operating expenses only as delineated in FAR 61.113 (fuel, oil, airport expenditures, or rental fees), up to a maximum of $350 per participant.

Maximum that can be reimbursed to you for this trip:
(Multiply $350 by the "Total # of Occupants" from above): $   

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**Certification of Accuracy**

In lieu of a signature, typing an ""X"" in the box at right indicates that you certify that the figures entered above are true and accurate to the best of your knowledge. (Please note that this certification is required for reimbursement approval.)"

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**Village/Runway Information**

Village 1

Village Name:	
Village Comments:
Hotel Name:	
Hotel Location:
Restaurant Name:	
Restaurant Location:
Other Comments:

Village 1 Airport

Runway Length:	
Heading:	
Runway Condition:
Runway Elevation:	
Windsock:	
Runway Comments:
Other Comments:


Village 2

Village Name:	
Village Comments:
Hotel Name:	
Hotel Location:
Restaurant Name:	
Restaurant Location:
Other Comments:

Village 2 Airport

Runway Length:	
Heading:	
Runway Condition:
Runway Elevation:	
Windsock:	
Runway Comments:
Other Comments:


R&R Site, If Any

Village Name:	
Village Comments:
Hotel Name:	
Hotel Location:
Restaurant Name:	
Restaurant Location:
Other Comments:

R&R SIte Airport
Runway Length:	
Heading:	
Runway Condition:
Runway Elevation:	
Windsock:	
Runway Comments:
Other Comments:

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**Regulatory or Customs Difficulties or Comments**





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LMV Volunteer Pilot Report & Claim for Reimbursement	Form Last Updated 4/26/06