Claim Form
What is your role at SSCS?
*
Please Select
Teacher/TA/ASP/Office other than District
Cafe/Custodial/District Office/IT/Transportation
Other/Community/Parent/Student
Name
*
First Name
Last 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
City
State / Province
Postal / Zip Code
What type of payment(s) are you claiming?
*
Please Select
Wages, Hourly Pay (Chaperone/Tutor/PD/ASP)
Stipends (Advisers/Coaches/Mentors)
Longevity Bonus
Mileage
Clothing Allowance
College Coursework
Other Pre-approved expense
Only one type of payment per form. Additional types of payments require separate form submissions.
What is the funding source for this payment?
*
Please Select
After School Program
Extra-Curricular (Specify below)
General Fund
Grant (Specify below)
Special Programs (Specify below)
Unknown
Only one payment source per form. Additional types of payments require separate form submissions.
Date of expenditure:
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-
Month
-
Day
Year
Date Picker Icon
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?
*
Yes
No
Date of expenditure:
*
-
Month
-
Day
Year
Date Picker Icon
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?
*
Yes
No
Date of expenditure:
*
-
Month
-
Day
Year
Date Picker Icon
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?
*
Yes
No
Date of expenditure:
*
-
Month
-
Day
Year
Date Picker Icon
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?
*
Yes
No
Date of expenditure:
*
-
Month
-
Day
Year
Date Picker Icon
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?
*
Yes
No
Date of expenditure:
*
-
Month
-
Day
Year
Date Picker Icon
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?
*
Yes
No
Date of expenditure:
*
-
Month
-
Day
Year
Date Picker Icon
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?
*
Yes
No
Date of expenditure:
*
-
Month
-
Day
Year
Date Picker Icon
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.
Browse Files
Drag and drop files here
Choose a file
Examples include itemized receipts, map verification of mileage, proof of grades/payments, pre-approvals, etc.
Cancel
of
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.
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