Application for Reimbursement for Private Transportation or Maintenance of Isolated Pupils
General Instructions: Parents will use this form to apply for isolation each school year. Once approved, parents will utilize the Request for Isolation Reimbursement form for reimbursements. In no case can the amount claimed exceed the actual costs incurred by the pupil or his/her parent or legal guardian. Do not include any costs for which reimbursement has been or will be claimed under the special education provisions of the School Foundation Program.
Name of Applicant (Parent or Guardian)
*
First Name
Last Name
Family Physical Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Is your mailing address the same as your physical address
*
Yes
No
Family Mailing Address
Mailing Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
example@example.com
Type of Isolation
*
Private Transportation
Maintenance
If approved, I would like to submit the mileage logs:
Digitally (Fill out and submit online)
By Mail/Drop off
Reimbursement is requested for the following pupil(s). Please list all students:
*
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Mileage Reimbursement for Use of Personal Vehicle
Reimbursement under this section must be based on actual miles traveled by one vehicle in one school day, regardless of the number of students transported. W.S. 21-4-401 (d) further requires that "... the total miles claimed shall be computed excluding the first two (2) miles traveled each way. You will begin counting mileage where your driveway meets the road. Do not count any part of your driveway. The mileage reimbursement rate is based on the current IRS business mileage reimbursement rate. Our goal with the following section is to determine the allowable number of miles from the end of your driveway to the bus.
What is the mileage from the end of your driveway to the bus stop - one way?
*
Number of miles
The number of miles listed above minus two (2) miles will be the amount reimbursement is based on when filling out the reimbursement log. You will enter these miles for AM trip to the bus, AM trip home, PM trip to the bus, PM trip home.
I certify that the above information is true and correct to the best of my knowledge and belief. I further certify that the ability to earn a substantial portion of our family income is directly related to and enhanced by the family residing in the isolated location listed in the family address space at the top of this form.
*
Date
*
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Month
-
Day
Year
Date
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