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Washington Service Corps - Individual Placement Program
In-Kind Match Report
Program Year: 2011-2012
A B C D E
# of Awarded Match Match Match Total Balance
Members Budget Reported this Previously Reported Due
$5,000/member Period Reported To date
(B + C) (A - D)
Program Operating Costs
Personnel Expenses 7311 $ - $ - $ - $ - $ -
Personnel Fringe Benefits 7314 $ - $ - $ - $ - $ -
Staff Travel 7330 $ - $ - $ - $ - $ -
Member Travel 7335 $ - $ - $ - $ - $ -
Supplies 7340 $ - $ - $ - $ - $ -
Staff Training 7312 $ - $ - $ - $ - $ -
Member Training 7320 $ - $ - $ - $ - $ -
Other Program Operating Costs 7342 $ - $ - $ - $ - $ -
Total $ - $ - $ - $ - $ -
The amounts above accurately summarize in-kind match documented for this AmeriCorps grant during the report period.
Authorizing Signature / (Date)
Report Ending
Date Due Date
Print Name & Title Report Period: Nov. 30, 2011 Dec. 15, 2011
(circle one) Feb. 28, 2012 Mar. 15, 2012
May 31, 2012 Jun. 15, 2012
Project Name:
WSC Project Coordinator Signature (Date)
WSC Finanical Manager Signature (Date)
Entered By: (Date)
Original - WSC Project File Draft 02/10/10
Copy - Partner Organization File
Washington Service Corps
2011-12 Receipt Voucher
In-Kind Contribution
Project Name:
Address:
Donor's Name: Phone Number:
Donor's Complete Address:
$0.00
Report Ending Date: Total Value $:
A separate voucher needs to be completed for each line item category. Circle the appropriate budget line item
for donation category. 7311 7314 7330 7335 7340 7312 7320 7342
Basis for Valuation
Description $ Value (market value of property, employee rate
of pay, receipts, etc. )
$0.00
$0.00
$0.00
If federal funds are used in reporting in-kind, the source of those federal funds must be contacted
and approve the use of those funds as match contribution to the WSC federal award. A copy of the
approval should be submitted to WSC prior to the report of the contribution.
Authorized Donor Signature
Signature and Date
Print Name:
Original - WSC
Copy - Partner Organization File Authorized Partner Organization
Signature and Date
Print Name:
Revised 09/01/08
WSC Site Supervisor Wage
Worksheet
Date:
Project Name:
Member: Site Supervisor:
The calculation of site supervision is based upon the number of hours in a report period a member is directly
supervised, i.e., one-on-one meeting and discussion between member and supervisor. Site supervision is not based on
the number of hours the member is physically located in the school, the classroom, or the service site.
The hours of direct supervision donated are multiplied by the actual salary rate of the site supervisor. Inclusion of
fringe benefits in calculating the value of an individual’s time is appropriate, and is calculated as a percentage of the
hourly rate.
What is your hourly pay rate? A
Take your monthly gross salary and divide it by 173.33 (average # of working hours in a month). Adjust if not
full-time.
$0.00
Monthly Gross Salary: 173.33 = $0.00
What is your benefits percentage rate? B
Talk with your human resources or accounting person to find out this percentage. According to a survey of
area schools/organizations, the average percentage rate for benefits is 30%. If you are unable to find out the
exact percentage, please use 30%.
If you do not receive benefits, please put 0.
What is your total hourly rate with benefits? C
Multiply the number in box A. by the percentage in box B. Add the resulting number to the number in box A.
and this is your total hourly rate with benefits. $0.00
Example: Mr. Smith is a teacher at Wilson Elementary School and his gross monthly income is $3,200.
For box A , he would put $18.46 (3,200/173.33).
Human resources told him that his benefits percentage is 31%, so in box B , he would put 31%.
His total will automatically calculate in box C .
Site Supervisor Signature:
Signature of Site Supervisor Date
SIGN IN INK
Print Name
WSC - Work Space Worksheet
Date:
Project Name:
Site Supervisor:
Member:
Project Name:
Source Document for Value:
Space Cost Guidelines
Dedicated space is the space that only members use at all times (desk, work area, files, etc.). and
must be verifiable from records and must show how the value was derived. If the space is shared by
others or not used at all times by your members it becomes less verifiable as an allowable donation.
We strongly prefer that you start with just the dedicated space provided.
After you determine the actual space size, get the value of that space from a specific source (either
the school district, county assesor's office, the school itself, or the city etc.). This would be the
source documentation for the market value, or what would be charged to others for its use. It may
vary in geographic locations. If the space is used by others normally without a charge, it is not
allowable as in-kind.
To calculate the square foot value/month, divide the annual value by 12 months per year.
Square Footage Value Per Value/Square Foot
Service Site
Dedicated Space Square Foot Per Month
$0.00
$0.00
$0.00
Total - $0.00
Project Staff Verifying Value (Print Name) Signature
Date:
IN-KIND CONTRIBUTION
MONTHLY REPORT
AmeriCorps*State Members Only
Site: Site Supervisor:
Project Name: Quarter/Year
Hours/______ Hours/______ Hours/______
Date: (Month) (Month) (Month)
1
2 Site Supervisor Signature
3
4
5
6 Site Supervisor Signature: Date
7 SIGN IN INK
8
9
10
11
12
13
14
15
16
17 AmeriCorps Coordinator Signature:
18
19
20
21 Signature of Coordinator Date
22 SIGN IN INK
23
24
25
26
27
28
29
30
31
Total Hours: 0.00 0.00 0.00
Total Hours This Period 0.00
