Form III
Complete the report with organization details, previous draws, participant totals, expenses, draw calculations, and certification.
Reimbursement Request
Agency / Organization
*
Fiscal Year
*
Reporting Period (Month)
*
2026-2027 Fiscal Year Base Allocation
Program Administrative Fee
Total Award
*
Previous Payments
Payments Received
Total Previous Payments
Current Participant / Enrollment Totals
Grade / Category
SSL
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Other
Total Enrollments
Expenses for Current Reporting Period
Salaries - Current Period
Payroll Related Expenses - Current Period
Travel & Training - Current Period
Space / Occupancy - Current Period
Office Supplies & Materials - Current Period
Equipment - Current Period
Other Expenses - Current Period
Total Expenses
Draw Calculation
Balance Before Current Draw
Current Draw Request
Balance After Current Draw
Certification
I certify that the information reported above is accurate and that all amounts represent allowable expenses.
Prepared By
*
First Name
Middle Name
Last Name
Prepared By - Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Authorized Representative
*
First Name
Middle Name
Last Name
Title
*
Signature
*
Signature - Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
Should be Empty: