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					                               DFM Faculty Cell Phone Service Reimbursement Request

                     Requesting Employee's Name:                                                              (rev. 09/2010)

                   Requesting Employee's Address:



                    DFM Budget Unit Incurring Cost:


GUIDELINES
Faculty with a clinical practice are reimbursed for voice usage fees at a fixed rate according to the DFM Faculty Business
  Expenses policy. Faculty with a leadership role may also be reimbursed for cellular data usage fees required for DFM
  business, if pre-approval is obtained from a DFM Vice-Chair or Chair and the budget manager for the unit incurring the cost.
For costs incurred from January through June, a properly completed request must be submitted to DFM Accounts
Payable by July 10th to be reimbursed. Costs incurred from July thru December must be submitted by January 10th.
Reimbursement may be requested monthly or quarterly.


CALCULATION OF DFM BUSINESS COST - **Attach portion of bill that lists these costs**

Month

Voice Access/Usage fees (from bill)                      A
Data Access/Usage fees (from bill)                       B
 Total Access/Usage fees                               C=A+B            -               -        -
Taxes/Surcharges (from bill)                             D
 Total Bill (Excluding penalties/late fees)            E=C+D            -               -        -

DFM business percentage of data usage (estimate)          F

Data Access/Usage Fees - DFM Business                  G=BxF            -               -        -
  as % of total access/usage fees                      H=G/C                0%              0%       0%
Taxes/Surcharges - DFM Business                        I=DxH            -               -        -
 Total Cost - DFM Business                             J=G+I            -               -        -        -
Limit (if any) set by supervisor                         K
Reimbursement (lesser of J or K)                         L              -               -        -        -


CERTIFICATION AND APPROVAL

I certify that this cost submitted for reimbursement is for DFM business, has been incurred by me,
and is not being reimbursed by any other source.


Requesting Employee's Signature                                                  Date



               DFM Budget Unit Manager Approval:

                                      Date Approved:

				
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