Form Reimbursement Claim by 33iLhq


									                                                             REIMBURSEMENT CLAIM
                                                    District of Columbia Highway Safety Office
                                                         Transportation Safety Policy Division
                                                     2000 14th Street NW, Washington, DC 20009
                                                       PHONE 202.671.0492/FAX 202.671.0617
                                                   (Note: Be sure to review instructions before completing form.)

Project Title:
Project Agency:
Project #:                                                Period Covered:                                        through
Final Claim?                              Reimbursement Claim will not be processed without accompanying
   Yes     No                                   Status Report & Reimbursement Itemization Report.
Reimbursement to be made to:

                                                                        Fund Recipient

                                                              Street Address, City, State, Zip
    Check here if address has changed
    Cost Category               Reimbursement                  Cumulative                   Reimbursement        Total Reimbursement            Non-
                                   Limitation                Reimbursement                  Requested This        Requested To Date         Reimbursable
                                                               Previously                       Period                                      Expenditures
                                                               Requested                   (in whole dollars)                                This Period
Salaries & Benefits                                 $0                            $0                        $0                         $0                  $0
Trvl, Trng & Conf Fees                              $0                            $0                        $0                         $0                  $0
Contractual Services                                $0                            $0                        $0                         $0                  $0
Equipment                                           $0                            $0                        $0                         $0                  $0
Other Direct Costs                                  $0                            $0                        $0                         $0                  $0
Indirect Costs                                      $0                            $0                        $0                         $0                  $0
Total                                               $0                            $0                        $0                         $0                  $0
Is reimbursement, in whole or in part, being requested for any Equipment having a
per unit cost of $1,000 or more?                                                                                                 Yes          No
    If yes, did you request & receive an approval letter from DC HSO prior to the purchase?                                      Yes          No
    If yes, an Equipment Accountability Report must be attached for each such item.
Is reimbursement being requested for any Educational Materials, Incentive Items
or Media?                                                                                                                        Yes          No
    If yes, did you request DC HSO review & receive prior approval for the production of these items?                            Yes          No
    If yes, a sample of each must be attached, for DC HSO files.
Is reimbursement being requested for any Out-of-State Travel not detailed in the
Project Agreement/CTSP Activity Request?                                                                                         Yes          No
    If yes, did you request & receive prior approval for this travel?                                                            Yes          No
Has any Program Income been generated directly by this project?                                                                  Yes          No
    If yes, has all such income been deducted from project expenditures?                                                         Yes          No

The information provided herein is accurate, and the above-requested reimbursement represents true and actual expenditures during this period in accordance
with the terms and conditions of the Project Agreement. Documentation supporting these expenditures is on file and availabile for review by DC HSO upon
                                                 Date                                                                            Date
           Project Director Signature                                                    Other Official Signature (Optional)
                                                                  FOR DC HSO USE ONLY
DC HSO Coordinator Signature:                                                                                            Date:

                                                                        FOR FMS USE ONLY
Entered into GMS:                                                                 Entered into FMIS:
                                     Initials               Date                                                    Initials       Date
Voucher #:

Financial Officer Signature:                                                                                             Date:
                                                                                                                                            Form 2 - RC (12/03)

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