SPAN
REQUEST
FOR REIMBURSEMENT
Name:
Date:
|
Item/Service Purch. |
Purpose |
Grant(s) to be Charged (% or $ amount) |
$ |
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O |
PIRC |
SCHS |
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Child Care |
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Equipment |
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Furniture (Only PIRC) |
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Library |
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Meeting Expense |
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Membership |
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Postage |
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Printing |
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Supplies |
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Telephone |
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Training Materials |
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TOTAL |
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INSTRUCTIONS:
1. List all expenditures by budget line
name. (see list on back)
2. Attach receipts for all
expenditures.
3. List all grants that are to be charged
for all expenditures.
4. *Note the % or $ amount of each
expenditure to be charged to each grant.
APPROVED
BY: _________________________________
Project
Director/Coordinator
______________________________________________________________________________
FOR FISCAL USE ONLY:
Date reimbursed
__________ Check # ________________
Executive
Director/Associate Director ____________________________ Date_____________