| 1. |
County/City Code: Division Code Number
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| 2. |
Project Number: Project Number (the division code and 01 or 02) |
| 3. |
Reimbursement Request Number: Number of this request. |
| 4. |
Division: The name of the school division requesting reimbursement. |
| 5. |
Contact Person: The person responsible for the program. |
| 6. |
Phone: For the Contact Person. |
| 7. |
Budgeted Amount: Dollar amount by expenditure category as shown on your approved budget. |
| 8. |
Current Expenditure: The amount of expenditure, for which you are requesting reimbursement. |
| 9. |
Year to Date Expenditure: The cumulative total of all requests, including this one. |
| 10. |
Total: The total amount for each column. |
| 11. |
Funds Approved: Leave this column blank; it is for State Use Only. |
| 12. |
Division Name: Division requesting reimbursement. |
| 13. |
Period: The dates for the period of time that funds are being requested. (i.e.9/1/02-10/30/02) |
| 14. |
Total Amount Claimed on this Request: Add the total Current Expenditures for this request. This is the total amount that is being requested for reimbursement. |
| 15. |
Prepared By: The name of the person who prepared the request. |
| 16. |
Phone Number: The phone number of the person who prepared the request. |
| 17. |
Division Superintendent/Designee: The superintendent or the designee must sign and date the request in BLUE ink. This must be an original signature. Faxes are not allowable for reimbursement. |
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Return request to:
Billie Reid LEA Title II, Part A Mgr.
Virginia Department of Education
PO Box 2120
Richmond, Virginia 23218-2120 |
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Request for Reimbursement FORM —
NCLB Title II, Part A, Teacher and Principal Training and Recruiting Fund (Word document) (PDF) |
