2011 12 TSR Allowable Reimbursements Worksheet blank

							2011-12 TSR! Reimbursement Worksheet
Agency Name:
Contract Period:             October 1, 2011 - August 31, 2012




                                              Full Time      Salary            Fringe
                                             Equivalence    (Oct. 1, 2011 -   (Oct. 1, 2011 -
field staff name             Position        (FTE)          July 31, 2012)    July 31, 2012)




Name/contact information - for contract to be sent to
Name:
Title:
email address:
Phone:


Name/contact information - for invoices/finance related business
Name:
Title:
email address:
Phone:

Name/contact information - for project related business
Name:
Title:
email address:
Phone:
                                                   Personal
                                                   Cell Phone      Estimated
                                                   Supplement      # miles in local
 Salary         Fringe          Total Amount       not to exceed   travel (per
(August, 2012) (August, 2012)   Salary & Fringe    $60/month       month)
                                 $             -
                                                            office
                      Total Mileage                        equipment           estimated office
 reimbursement        (maximum              Office Space   provided           space &equipment
rate (not to exceed   reimbursement for     provided:      (please list all   supplement (not to
.55/mile)             mileage - $6,000)     # of sq/ft     items)             exceed $2,000)
                       $                -
 Office &
Training
supplies
$500 per F/T
staff          Total