Reimbursement Form and Receipt

Academic Enhancement Plan (AEP) Reimbursement Form and Receipt

You have used your own funds $$ to purchase items.
Reimbursement:

If you have already purchased APPROVED items, please attach the receipts for reimbursement. It is important that your receipts highlight the specific items related to your scholar(s) requests.
1. If your scholar is struggling academically, we will only approve requests to support them academically, i.e. tutoring, counseling, brain training, etc.
2. Requests must be received no later than the 10th of the month.
3. We only approve 50% of funding per semester.
  K-8 scholars: $900/year per scholar. Up to $450.00 can be requested each semester.
  High School scholars: $1200/year per scholar. Up to $600.00 can be requested each semester.
4. A W-9 must be completed before a check is issued to you.
Please ONLY submit (1) form for ALL scholar requests MONTHLY.
What County do you live in?
Received Approval for Reimbursement. If NO, we will review and let you know if your reimbursement will be approved.*

YesNo
Parents Name:*

First NameLast Name
Scholar Name 1: *

First NameLast Name
Scholar Education Option:*

Traditional Public (District Schools)Charter Public (Independent Public Schools)Homeschool (At Home Instruction/even if connected with homeschool connection programs)Private (Tuition Based - Full or Hybrid (2/3 days Homeschooling)
Scholar Grade:*

K-89-12
Please note request for Scholar 2 (if you have NO request for scholar 2 proceed to details of request)*

YesNo
Scholar Name 2:

First NameLast Name
Scholar Education Option:

Traditional Public (District Schools)Charter Public (Independent Public Schools)Homeschool (At Home Instruction/even if connected with homeschool connection programs)Private (Tuition Based - Full or Hybrid (2/3 days Homeschooling)
Scholar Grade:

K-89-12
PARENT COORDINATORS ONLY

If you are NOT a Parents Challenge Parent Coordinator, please do not request reimbursement for a 3rd child.
Please note request for Scholar 3 (if you have NO request for Scholar 3 proceed to details of request)*

YesNo
Scholar Name 3:

First NameLast Name
Scholar Education Option:

Traditional Public (District Schools)Charter Public (Independent Public Schools)Homeschool (At Home Instruction/even if connected with homeschool connection programs)Private (Tuition Based - Full or Hybrid (2/3 days Homeschooling)
Scholar Grade:

K-89-12
DETAILS OF REQUEST
Based on my scholar(s) academic performance in school, I have used the Parents Challenge Grant money to help improve his/her performance in: (Please ONLY select the categories that relate to the actual use of funds).*

Technology, i.e. computer/laptop, printer, cartridges, softwareAcademic Performance, i.e. tutoring, counseling, brain trainingMath Skills, i.e. tutoring, software programs, books, online resourcesReading Skills, i.e. tutoring, books, online resources, reading success skillsWriting Skills, i.e. tutoring, software programs, books, online resourcesScience Skills, i.e. tutoring, software programs, books, online resourcesSocial Aptitude, i.e. sports, music, theater, karate, gymnasticsMental Health, i.e. counseling, play therapy (we do not pay for prescriptions)Transportation, i.e. bus pass, bike (traveling to/from school), mileage # of miles to and from school x .13/mile (must provide gas receipts)Clubs, Speech, Camps, School tripsUniforms (we do not purchase regular cloths, shoes, etc.)Other
To help my scholar(s) improve in these areas, I used the financial resources for the following. Please be specific on how the funds were utilized and the specific amounts spent:*
Total Amount Requested for Reimbursement:*
The amount must match the receipts submitted. If you purchased items not related to request, please mark them out so they are not visible with request.
Receipt(s):*

Browse Files

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Receipt(s):

Browse Files

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Receipt(s):

Browse Files

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Do you prefer an electronic payment or paper check?*

ElectronicPaper Check
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Should be Empty:

Academic Enhancement Plan (AEP) Reimbursement Form and Receipt

PARENT COORDINATORS ONLY

DETAILS OF REQUEST