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					                                                       NORTH DAKOTA DEPARTMENT OF PUBLIC INSTRUCTION
                                                                SCHOOL DISTRICT FINANCE OFFICE
                                                        600 EAST BOULEVARD AVE, BISMARCK ND 58505-0440

                                     AMERICAN RECOVERY AND REINVESTMENT ACT (ARRA)
                                 EDUCATION JOBS FUND PROGRAM REQUEST FOR REIMBURSEMENT


Name of School District:
Contact Person:                                                                                                                        Grant Award Amount:          $                                  -
Contact Phone Number/Email:


Payroll Expenditures (Must be accompanied by the school district ledger)
                                                                    Funding Start Date
                                          License Number (if        (Cannot be prior to                                                                                            Total Salary/Benefits
  Position Title:     Name of Employee applicable)                  08/10/2010)                   Funding End Date       Project Code Program Code   Function       Object         Expenditures
Example:
Teacher                  John Smith                                        1/1/2011                          3/31/2011           092           120           1000            110                     4,000




If additional lines are required, please use 'Employees' worksheet                                                                     Total                                       $                   -


Other Expenditures
Other Expenditures                                                   Amount                   Description of Other Expenses




                                                  Total                                   0


                       Total Reimbursement Requested (Salary + Fringe + Other)                                                         $                                     -


Signature of Authorized Representative:
Date:
Additional Worksheet for Salary and Fringe Benefit Expenditures
                                                                      License Number (if   Funding Start Date                                                                         Total Salary/Benefits
                                                                                             (Cannot be prior to
    Position Title:                   Name of Employee                applicable)               08/10/2010)
                                                                                                                   Funding End Date   Project Code Program Code   Function   Object   Expenditures




These totals will carry forward to the total on the first worksheet                                                                               Total                               $                       -

				
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