Free 53846.pdf - Indiana

Reset Form

JUSTIFICATION OF TAKE HOME VEHICLE ASSIGNMENT
State Form 53846 (R / 3-09)

DEPARTMENT OF ADMINISTRATION FLEET SERVICES DIVISION 601 W McCarty Street Indianapolis, IN 46225 Fax: (317) 233-4881

INSTRUCTIONS:

1. Complete this form annually for each assigned take home vehicle. Forms must be submitted by May 1 each year or whenever a take home vehicle is newly assigned or reassigned. 2. Return completed forms to: IDOA Fleet Services, 601 W. McCarty, Indianapolis, IN 46225 or by Fax to (317)233-4881. 3. Direct all inquiries to Fleet Services at (317) 232-1379 or via e-mail to [email protected].

Public Law [P.L. 234-2007, Section 24] requires agency heads to annually submit justification for the continued assignment of a take home vehicle to any state employee. Each agency head has discretion to decide whether a take home vehicle may be assigned to a qualifying employee within the provisions of Public Law and the State's Vehicle Fleet Management Policy. Employee Name: Agency/Department: Section/Division: Job Title: Vehicle location when off duty: Comm. number of assigned vehicle: Vehicle Description (Make, Model): Vehicle ID Number (VIN): 1) Is the vehicle assigned to an elected State official? Yes No If `Yes', answer question 1-A below and then submit the form. If `No', proceed to question 2. 1-A) Do the duties of the office require driving about the state of Indiana in the performance of official duty? Yes No 2) Is the vehicle assigned to a Department or Commission Head? Yes No `Yes', answer question 2-A below and then submit the form. If `No', proceed to question 3. If Vehicle Year: Phone: Driver's Lic. #: Expiration Date:

1

2-A) Do the statutory duties imposed in the discharge of the office require travel greater than 1,000 miles per month1 OR is the employee subject to official duty call at all times? Yes No
Commuting miles may not be included in the 1,000 mile computations. (Continued on reverse)

Page 1 of 2

3) For all other state employees, does a major portion of the duties assigned to the employee require travel on state business in excess 1,000 miles per month1 OR has the agency identified the vehicle as an integral part of the job assignment? Yes No If `Yes', answer questions 3-A through 3-D below. If `No', submit the form.
1

Commuting miles may not be included in the 1,000 mile computations.

3A) Does the position require the employee to be on call on a recurring basis beyond normal duty hours and, when called out, require immediate travel from a residence to a location where specific skills, services, tools, equipment or supplies are necessary to perform the job? Yes No 3B) Does the position involve leaving directly from home to a continually variable work station, in which travel to a central location to obtain a state-owned vehicle would result in significant amounts of unnecessary travel time and loss of productive hours? Yes No 3C) Does the employee work from a home office with a continually variable work station (e.g. inspectors, case workers, investigators, etc.)? Yes No 3D) Is the employee a law enforcement officer or a public safety emergency responder? Yes No

Prepared by:

Date:

Approved by:

Date:

Comments:

Page 2 of 2