
ATTACHME NT B ANNUAL SCHOOL LEADERSHIP TEAM
REMUNERATION REQUEST FORM
PLEASE READ INSTRUCTIONS BEFORE COMPLETING
State
Total
Hours
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
QUICK CODE OBJECT
CODE
$AMOUNT
FUNDS ARE AVAILABLE - CHARGE TO:
DISTRICT
SIGNATURE OF APPROVING OFFICER DATE
I approve this expenditure certifying that it is necessary for the conduct of
the educational or administrative program and is in accordance with the
rules and regulations of the Board of Education and applicable funding
source guidelines.
____________________________________ _____________
_______________________ _________
PROCESSED ON-LINE BY DATE
_______________________ ________
I certify that the above claimant has met the obligations as a member of the School Leadership Team and that he/she has
participated in the program's activities for the hours described in section two (2) above and shall be remunerated for fees
incurred as a result of these activities.
_______________________________________________________________ _______________
SIGNATURE OF LIAISON FOR FINANCIAL MATTERS DATE
SECTION 5 FOR DISTRICT/CENTRAL OFFICE USE ONLY
I certify that I have met the obligations as a member
of the School Leadership Team and that I have
participated in the program's activities for at least
thirty (30) hours as described in section two (2) and
thus request the appropriate remuneration.
(Pro-rated remuneration is permisible if the team
has agreed to it.)
_________________________________________
_________________________________________
_________________________________________
DATE
TEAM MEMBER CERTIFICATION
SECTION 4 LIAISON FOR FINANCIAL MATTERS CONFIRMATION
Ex
: From 6:00 P.M. to 8:00 P.M.
From To
MM DD YY
This claim form is to be used only by members of the School Leadership Team to record attendance at team activities. Team members will complete the
information in the first 3 sections of this claim form, and before June 15th of each school year, forward the original form to the team's Liaison for Financial
Matters, who will confirm the attendance by signing in section 4. The Liaison for Financial Matters will forward the original claim to the Approving Officer at
the appropriate Community School District or high school office for review, signature, completion of budget information and payment processing through the
On-line Imprest Fund System. Fifteen business days from the time the central or district payment processing office receives the claim are needed for the
check to be issued and received in the mail. This form is to be used by School Leadership Team Members in lieu of the standard "Authorization for Imprest
INSTRUCTIONS
SECTION 2 ACTIVITIES
SECTION I TEAM MEMBER INFORMATION
District
Name of Team Member
Mailing Address (Number & Street) Apartment Number
City Zip Code
School Name
AUTHORIZED BY
LOCATION CODE PAYMENT PROCESSED ON-LINE