Foster Care Mileage & Expense
Reimbursement Form
Foster Parent(s)
*
Please Select
Barnhart, Zac & Madison
Beeler, Katie
Bridges, Jason & Amy
Burdine, Beth
Campbell, Miles & Ashley
Deime, Michael & Jessica
DeVries, Zachary & MacKenzie
Gambrell, Chris & Brittany
Giles, Phillip & Jennifer
Johnson, Kalyca
King, Samuel & Lindsey
Lakes, John & Jennifer
Lee, Eric & Grayson
Leonard, Sierra
McKoy, Claire
McLellan, Brian & Amy
Moldenhauer, Sam & Ariel
Nicholson, Russell & Sarah
Osterbrook, Ken & Kathryn
Pleman, Nova
Radford, Casondra
Roberts, Matthew & Jessica
Wade, Michael & Twana
Walters, Justin & Kelly
Wiehe, Lisa
Foster Parent Email #1
example@example.com
Foster Parent Email #2
example@example.com
Foster Parent Address
Street
Foster Parent Address
City / State / Zip
Invoice Period
*
Please Select
January 2024
February 2024
March 2024
April 2024
May 2024
June 2024
July 2024
August 2024
September 2024
October 2024
November 2024
December 2024
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Foster Child #1
Child #1 (Barnhart)
*
Please Select
Jai'Shon Waddy
Reshon Coffey
Child #1 (Beeler)
*
Please Select
Lucina Gonzales-Ortega
Child #1 (Bridges)
*
Please Select
Addilyn Thomas
Child #1 (Campbell)
*
Please Select
Isaiah Combs
Child #1 (Deime)
*
Please Select
Sofia Campbell
Child #1 (Gambrell)
*
Please Select
Jamie Brown
Paul Brown
Tyler Brown
Child #1 (Giles)
*
Please Select
Logan Caseltine
Child #1 (King)
*
Please Select
Kaelyanna Harding
River Harding
Child #1 (Lakes)
*
Please Select
Jace Griffin
Ma'Kenzie Griffin
Child #1 (Lee)
*
Please Select
Andreana Caudill
Arron Davis
Skarlette Davis
Child #1 (McKoy)
*
Please Select
Silas Meyers
Child #1 (McLellan)
*
Please Select
Amiya Venegas
Child #1 (Nicholson)
*
Please Select
Isabel Johnson
Kairi Slone
Killian Slone
Child #1 (Osterbrook)
*
Please Select
Shaylin Phillips
Tayshauna Poyntz
Child #1 (Pleman)
*
Please Select
Hector Bernal-Garcia
Miranda Bernal-Garcia
Child #1 (Roberts)
*
Please Select
Rhuheem Caldwell
Zay'Dyn Trusty
Child #1 (Wade)
*
Please Select
Mikael Morrison
Atlas Morrison
Child #1 (Walters)
*
Please Select
Elias Jones
Child #1 (Wiehe)
*
Please Select
Joseph Sanders
Waylon Sanders
Last Name
Child #1
First Name
Child #1
County of Origin
Child #1
Date of Birth
Child #1
Twist Number
Child #1
SSN
Child #1
Date of Admission
Child #1
Service Type
Child #1
Do you have miscellaneous expenses for THIS CHILD that need to be reimbursed this month?
*
YES
NO
EXPENSE REPORTING
Foster Child #1
How many miscellaneous reimbursements are you submitting in this invoice for THIS CHILD?
*
Please Select
One (1)
Two (2)
Three (3)
Expense #1
Foster Child #1
Expense #1 Category
*
Please Select
BIRTHDAY
CHRISTMAS
CLOTHING LETTER
LIFEBOOK
SCHOOL PICTURES
SCHOOL SUPPLIES
SENIOR EXPENSES
Expense #1 Total
*
Expense #1 Receipt
*
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Expense #2
Foster Child #1
Expense #2 Category
*
Please Select
BIRTHDAY
CHRISTMAS
CLOTHING LETTER
LIFEBOOK
SCHOOL PICTURES
SCHOOL SUPPLIES
SENIOR EXPENSES
Expense #2 Total
*
Expense #2 Receipt
*
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Expense #3
Foster Child #1
Expense #3 Category
*
Please Select
BIRTHDAY
CHRISTMAS
CLOTHING LETTER
LIFEBOOK
SCHOOL PICTURES
SCHOOL SUPPLIES
SENIOR EXPENSES
Expense #3 Total
*
Expense #3 Receipt
*
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MISC. EXPENSE SUBTOTAL
CHILD #1
Do you have trips, over 40 miles (one-way) or over 80 miles (roundtrip), to report for this child?
*
YES
NO
MILEAGE REPORTING
Foster Child #1
How many trips, over 40 miles (one-way) or over 80 miles (roundtrip), will you be reporting for THIS CHILD that need to be reimbursed?
*
Please Select
One (1)
Two (2)
Three (3)
Trip #1
Foster Child #1
Trip Date
*
-
Month
-
Day
Year
Trip #1
Trip #1 Driving Distance
*
Was this a roundtrip?
*
YES
NO
Total Miles
Trip #1
Total Miles Allowed
Trip #1
Total Mileage Reimbursement
Trip #1
Total Mileage Reimbursement
Trip #1
Purpose of Trip
*
Please Select
Family Visit
Medical Appointment
Court Date
Social Worker
Trip #1
Trip #2
Foster Child #1
Trip Date
*
-
Month
-
Day
Year
Trip #2
Trip #2 Driving Distance
*
Was this a roundtrip?
*
YES
NO
Total Miles
Trip #2
Total Miles Allowed
Trip #2
Total Mileage Reimbursement
Trip #2
Total Mileage Reimbursement
Trip #2
Purpose of Trip
*
Please Select
Family Visit
Medical Appointment
Court Date
Social Worker
Trip #2
Trip #3
Foster Child #1
Trip Date
*
-
Month
-
Day
Year
Trip #3
Trip #3 Driving Distance
*
Was this a roundtrip?
*
YES
NO
Total Miles
Trip #3
Total Miles Allowed
Trip #3
Total Mileage Reimbursement
Trip #3
Total Mileage Reimbursement
Trip #3
Purpose of Trip
*
Please Select
Family Visit
Medical Appointment
Court Date
Social Worker
Trip #3
TOTAL MILEAGE ALLOWED SUBTOTAL
ALL TRIPS
TOTAL MILEAGE REIMBURSEMENT
ALL TRIPS
Do you have a SECOND CHILD to report on this invoice?
*
YES
NO
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FOSTER CHILD #2
Child #2 (Barnhart)
*
Please Select
Jai'Shon Waddy
Reshon Coffey
Child #2 (Gambrell)
*
Please Select
Jamie Brown
Paul Brown
Tyler Brown
Child #2 (King)
*
Please Select
Kaelyanna Harding
River Harding
Child #2 (Lakes)
*
Please Select
Jace Griffin
Ma'Kenzie Griffin
Child #2 (Lee)
*
Please Select
Andreana Caudill
Arron Davis
Skarlette Davis
Child #2 (Nicholson)
*
Please Select
Isabel Johnson
Kairi Slone
Killian Slone
Child #2 (Osterbrook)
*
Please Select
Shaylin Phillips
Tayshauna Poyntz
Child #2 (Pleman)
*
Please Select
Hector Bernal-Garcia
Miranda Bernal-Garcia
Child #2 (Roberts)
*
Please Select
Rhuheem Caldwell
Zay'Dyn Trusty
Child #2 (Wade)
*
Please Select
Mikael Morrison
Atlas Morrison
Child #2 (Wiehe)
*
Please Select
Joseph Sanders
Waylon Sanders
Last Name
Child #2
First Name
Child #2
County of Origin
Child #2
Date of Birth
Child #2
Twist Number
Child #2
SSN
Child #2
Date of Admission
Child #2
Service Type
Child #2
Do you have miscellaneous expenses for THIS CHILD that need to be reimbursed this month?
*
YES
NO
EXPENSE REPORTING
Foster Child #2
How many miscellaneous reimbursements are you submitting in this invoice for THIS CHILD?
*
Please Select
One (1)
Two (2)
Three (3)
Expense #1
Foster Child #2
Expense #1 Category
*
Please Select
BIRTHDAY
CHRISTMAS
CLOTHING LETTER
LIFEBOOK
SCHOOL PICTURES
SCHOOL SUPPLIES
SENIOR EXPENSES
Expense #1 Total
*
Expense #1 Receipt
*
Browse Files
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of
Expense #2
Foster Child #2
Expense #2 Category
*
Please Select
BIRTHDAY
CHRISTMAS
CLOTHING LETTER
LIFEBOOK
SCHOOL PICTURES
SCHOOL SUPPLIES
SENIOR EXPENSES
Expense #2 Total
*
Expense #2 Receipt
*
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Expense #3
Foster Child #2
Expense #3 Category
*
Please Select
BIRTHDAY
CHRISTMAS
CLOTHING LETTER
LIFEBOOK
SCHOOL PICTURES
SCHOOL SUPPLIES
SENIOR EXPENSES
Expense #3 Total
*
Expense #3 Receipt
*
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of
MISC. EXPENSE SUBTOTAL
CHILD #2
Do you have trips, over 40 miles (one-way) or over 80 miles (roundtrip), to report for this child?
*
YES
NO
MILEAGE REPORTING
Foster Child #2
How many trips, over 40 miles (one-way) or over 80 miles (roundtrip), will you be reporting for THIS CHILD that need to be reimbursed?
*
Please Select
One (1)
Two (2)
Three (3)
Trip #1
Foster Child #2
Trip Date
*
-
Month
-
Day
Year
Trip #1
Trip #1 Driving Distance
*
Was this a roundtrip?
*
YES
NO
Total Miles
Trip #1
Total Miles Allowed
Trip #1
Total Mileage Reimbursement
Trip #1
Total Mileage Reimbursement
Trip #1
Purpose of Trip
*
Please Select
Family Visit
Medical Appointment
Court Date
Social Worker
Trip #1
Trip #2
Foster Child #2
Trip Date
*
-
Month
-
Day
Year
Trip #2
Trip #2 Driving Distance
*
Was this a roundtrip?
*
YES
NO
Total Miles
Trip #2
Total Miles Allowed
Trip #2
Total Mileage Reimbursement
Trip #2
Total Mileage Reimbursement
Trip #2
Purpose of Trip
*
Please Select
Family Visit
Medical Appointment
Court Date
Social Worker
Trip #2
Trip #3
Foster Child #2
Trip Date
*
-
Month
-
Day
Year
Trip #3
Trip #3 Driving Distance
*
Was this a roundtrip?
*
YES
NO
Total Miles
Trip #3
Total Miles Allowed
Trip #3
Total Mileage Reimbursement
Trip #3
Total Mileage Reimbursement
Trip #3
Purpose of Trip
*
Please Select
Family Visit
Medical Appointment
Court Date
Social Worker
Trip #3
TOTAL MILEAGE ALLOWED SUBTOTAL
ALL TRIPS
TOTAL MILEAGE REIMBURSEMENT
ALL TRIPS
Do you have a THIRD CHILD to report on this invoice?
*
YES
NO
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FOSTER CHILD #3
Child #3 (Gambrell)
*
Please Select
Jamie Brown
Paul Brown
Tyler Brown
Child #3 (Lee)
*
Please Select
Andreana Caudill
Arron Davis
Skarlette Davis
Child #3 (Nicholson)
*
Please Select
Isabel Johnson
Kairi Slone
Killian Slone
Last Name
Child #3
First Name
Child #3
County of Origin
Child #3
Date of Birth
Child #3
Twist Number
Child #3
SSN
Child #3
Date of Admission
Child #3
Service Type
Child #3
Do you have miscellaneous expenses for THIS CHILD that need to be reimbursed this month?
*
YES
NO
EXPENSE REPORTING
Foster Child #3
How many miscellaneous reimbursements are you submitting in this invoice for THIS CHILD?
*
Please Select
One (1)
Two (2)
Three (3)
Expense #1
Foster Child #3
Expense #1 Category
*
Please Select
BIRTHDAY
CHRISTMAS
CLOTHING LETTER
LIFEBOOK
SCHOOL PICTURES
SCHOOL SUPPLIES
SENIOR EXPENSES
Expense #1 Total
*
Expense #1 Receipt
*
Browse Files
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of
Expense #2
Foster Child #3
Expense #2 Category
*
Please Select
BIRTHDAY
CHRISTMAS
CLOTHING LETTER
LIFEBOOK
SCHOOL PICTURES
SCHOOL SUPPLIES
SENIOR EXPENSES
Expense #2 Total
Expense #2 Receipt
*
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of
Expense #3
Foster Child #3
Expense #3 Category
*
Please Select
BIRTHDAY
CHRISTMAS
CLOTHING LETTER
LIFEBOOK
SCHOOL PICTURES
SCHOOL SUPPLIES
SENIOR EXPENSES
Expense #3 Total
*
Expense #3 Receipt
*
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of
MISC. EXPENSE SUBTOTAL
CHILD #3
Do you have trips, over 40 miles (one-way) or over 80 miles (roundtrip), to report for this child?
*
YES
NO
MILEAGE REPORTING
Foster Child #3
How many trips, over 40 miles (one-way) or over 80 miles (roundtrip), will you be reporting for THIS CHILD that need to be reimbursed?
*
Please Select
One (1)
Two (2)
Three (3)
Trip #1
Foster Child #3
Trip Date
*
-
Month
-
Day
Year
Trip #1
Trip #1 Driving Distance
*
Was this a roundtrip?
*
YES
NO
Total Miles
Trip #1
Total Miles Allowed
Trip #1
Total Mileage Reimbursement
Trip #1
Total Mileage Reimbursement
Trip #1
Purpose of Trip
*
Please Select
Family Visit
Medical Appointment
Court Date
Social Worker
Trip #1
Trip #2
Foster Child #3
Trip Date
*
-
Month
-
Day
Year
Trip #2
Trip #2 Driving Distance
*
Was this a roundtrip?
*
YES
NO
Total Miles
Trip #2
Total Miles Allowed
Trip #2
Total Mileage Reimbursement
Trip #2
Total Mileage Reimbursement
Trip #2
Purpose of Trip
*
Please Select
Family Visit
Medical Appointment
Court Date
Social Worker
Trip #2
Trip #3
Foster Child #3
Trip Date
*
-
Month
-
Day
Year
Trip #3
Trip #3 Driving Distance
*
Was this a roundtrip?
*
YES
NO
Total Miles
Trip #3
Total Miles Allowed
Trip #3
Total Mileage Reimbursement
Trip #3
Total Mileage Reimbursement
Trip #3
Purpose of Trip
*
Please Select
Family Visit
Medical Appointment
Court Date
Social Worker
Trip #3
TOTAL MILEAGE SUBTOTAL
ALL TRIPS
TOTAL MILEAGE REIMBURSEMENT
ALL TRIPS
Do you have a FOURTH CHILD to report on this invoice?
*
YES
NO
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FOSTER CHILD #4
Name - Child #4
*
Please Select
Acen Wallace
Addilyn Thomas
Andreana Caudill
Ani'yah Wallace
Armani Wallace
Arron Davis
Bianca Radcliff
Bryan Powers
Carmen Morales-Ortiz
Hannah Radcliff
Isaiah Combs
Jace Griffin
Jamie Brown
Juliana Maldonado
Kendra Kidd
Logan Caseltine
Ma'Kenzie Griffin
Maleena Robinson
Maria Poyntz
Mayleah Henry-Maldonado
Mikael Morrison
Noe Maldonado
Paul Brown
Rachel Mink
Skarlette Davis
Sofia Campbell
Tayshauna Poyntz
Last Name
Child #4
First Name
Child #4
County of Origin
Child #4
Date of Birth
Child #4
Twist Number
Child #4
SSN
Child #4
Date of Admission
Child #4
Service Type
Child #4
Do you have miscellaneous expenses for THIS CHILD that need to be reimbursed this month?
YES
NO
EXPENSE REPORTING
Foster Child #4
How many miscellaneous reimbursements are you submitting in this invoice for THIS CHILD?
Please Select
One (1)
Two (2)
Three (3)
Expense #1
Foster Child #4
Expense #1 Category
Please Select
BIRTHDAY
CHRISTMAS
CLOTHING LETTER
LIFEBOOK
SCHOOL PICTURES
SCHOOL SUPPLIES
SENIOR EXPENSES
Expense #1 Total
Expense #1 Receipt
Browse Files
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of
Expense #2
Foster Child #4
Expense #2 Category
Please Select
BIRTHDAY
CHRISTMAS
CLOTHING LETTER
LIFEBOOK
SCHOOL PICTURES
SCHOOL SUPPLIES
SENIOR EXPENSES
Expense #2 Total
Expense #2 Receipt
Browse Files
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of
Expense #3
Foster Child #4
Expense #3 Category
Please Select
BIRTHDAY
CHRISTMAS
CLOTHING LETTER
LIFEBOOK
SCHOOL PICTURES
SCHOOL SUPPLIES
SENIOR EXPENSES
Expense #3 Total
Expense #3 Receipt
Browse Files
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of
MISC. EXPENSE SUBTOTAL
CHILD #4
Do you have trips, over 40 miles (one-way) or over 80 miles (roundtrip), to report for this child?
YES
NO
MILEAGE REPORTING
Foster Child #4
How many trips, over 40 miles (one-way) or over 80 miles (roundtrip), will you be reporting for THIS CHILD that need to be reimbursed?
Please Select
One (1)
Two (2)
Three (3)
Trip #1
Foster Child #4
Trip Date
-
Month
-
Day
Year
Trip #1
Trip #1 Driving Distance
Was this a roundtrip?
YES
NO
Total Miles
Trip #1
Total Miles Allowed
Trip #1
Total Mileage Reimbursement
Trip #1
Total Mileage Reimbursement
Trip #1
Purpose of Trip
Please Select
Family Visit
Medical Appointment
Court Date
Social Worker
Trip #1
Trip #2
Foster Child #4
Trip Date
-
Month
-
Day
Year
Trip #2
Trip #2 Driving Distance
Was this a roundtrip?
YES
NO
Total Miles
Trip #2
Total Miles Allowed
Trip #2
Total Mileage Reimbursement
Trip #2
Total Mileage Reimbursement
Trip #2
Purpose of Trip
Please Select
Family Visit
Medical Appointment
Court Date
Social Worker
Trip #2
Trip #3
Foster Child #4
Trip Date
-
Month
-
Day
Year
Trip #3
Trip #3 Driving Distance
Was this a roundtrip?
YES
NO
Total Miles
Trip #3
Total Miles Allowed
Trip #3
Total Mileage Reimbursement
Trip #3
Total Mileage Reimbursement
Trip #3
Purpose of Trip
Please Select
Family Visit
Medical Appointment
Court Date
Social Worker
Trip #3
TOTAL MILEAGE SUBTOTAL
ALL TRIPS
TOTAL MILEAGE REIMBURSEMENT
ALL TRIPS
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MILEAGE & EXPENSE OVERVIEW
All Placements
Number of Expense Reimbursements Submitted
Expense Reimbursement Subtotal
ALL PLACEMENTS
Number of Mileage Reimbursements Submitted
Mileage Reimbursement Subtotal
ALL PLACEMENTS
GRAND TOTAL
ALL PLACEMENTS
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