Claim Form

Claim Form
What is your role at SSCS?*
Name*

First NameLast Name
Email*
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Mailing Address*

Mailing Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What type of payment(s) are you claiming?*
Only one type of payment per form. Additional types of payments require separate form submissions.
What is the funding source for this payment?*
Only one payment source per form. Additional types of payments require separate form submissions.
Date of expenditure:*

MonthDayYear
Amount requested:*
Detailed description of expenditure:*
Example: Travel location and roundtrip mileage, # of hours and hourly rate, stipends/allowances, etc. Please include specifics about the funding source here as well. Failure to provide adequate detail could delay payment.
Do you need to claim additional expenditures?*

YesNo
Date of expenditure:*

MonthDayYear
Amount requested:*
Description of expenditure:*
Example: Travel location and roundtrip mileage, # of hours and hourly rate, stipends/allowances, etc. Please include specifics about the funding source here as well. Failure to provide adequate detail could delay payment.
Do you need to claim additional expenditures?*

YesNo
Date of expenditure:*

MonthDayYear
Amount requested:*
Description of expenditure:*
Example: Travel location and roundtrip mileage, # of hours and hourly rate, stipends/allowances, etc. Please include specifics about the funding source here as well. Failure to provide adequate detail could delay payment.
Do you need to claim additional expenditures?*

YesNo
Date of expenditure:*

MonthDayYear
Amount requested:*
Description of expenditure:*
Example: Travel location and roundtrip mileage, # of hours and hourly rate, stipends/allowances, etc. Please include specifics about the funding source here as well. Failure to provide adequate detail could delay payment.
Do you need to claim additional expenditures?*

YesNo
Date of expenditure:*

MonthDayYear
Amount requested:*
Description of expenditure:*
Example: Travel location and roundtrip mileage, # of hours and hourly rate, stipends/allowances, etc. Please include specifics about the funding source here as well. Failure to provide adequate detail could delay payment.
Do you need to claim additional expenditures?*

YesNo
Date of expenditure:*

MonthDayYear
Amount requested:*
Description of expenditure:*
Example: Travel location and roundtrip mileage, # of hours and hourly rate, stipends/allowances, etc. Please include specifics about the funding source here as well. Failure to provide adequate detail could delay payment.
Do you need to claim additional expenditures?*

YesNo
Date of expenditure:*

MonthDayYear
Amount requested:*
Description of expenditure:*
Example: Travel location and roundtrip mileage, # of hours and hourly rate, stipends/allowances, etc. Please include specifics about the funding source here as well. Failure to provide adequate detail could delay payment.
Do you need to claim additional expenditures?*

YesNo
Date of expenditure:*

MonthDayYear
Amount requested:*
Description of expenditure:*
Example: Travel location and roundtrip mileage, # of hours and hourly rate, stipends/allowances, etc. Please include specifics about the funding source here as well. Failure to provide adequate detail could delay payment.
You have reached the maximum expenditures for this form.

Please start a new form if you need to claim additional expenditures.
Total Requested:
Attach documentation required to substantiate the request.

Examples include itemized receipts, map verification of mileage, proof of grades/payments, pre-approvals, etc.
Cancelof
Electronic Signature Required*
Please type your name to certify that said claim is just, due, and unpaid and that there are no offsets against the claim, that the items are reasonable and just, that no payment has been made on account thereof; except as included or referred to in such account or claim.
Should be Empty:

Claim Form

You have reached the maximum expenditures for this form.