Print and attach a copy of your NBRIC statement from the NBPTS by tamir13

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									                                                   KENTUCKY TEACHER’S NATIONAL CERTIFICATION TRUST FUND
                                                                                              2004-2005 CYCLE
                          SAMPLE ONLY – DO NOT RETURN
                    FINANCIAL STATEMENT FOR FEE VERIFICATION


First year fee $2,300          Fees for 2nd or 3rd years cannot be reimbursed. (16KAR 1:040
                               “The Education Professional Standards Board shall not reimburse
                                teacher for any fees associated with banking scores or retaking the
                                assessment.”

Minus –         $1150.00         Federal subsidies received 1st, 2nd, or 3rd year of candidacy.
                                 $575 Federal Subsidy
                                 or
                                 $1150 Appalachia Project

Minus -         $ 500.00         Scholarships from NBPTS
                                 Name of scholarship: State Farm Insurance

Minus -          $ 200.00        Any other Third Party payments (i.e. corporate, school
                                districts) that you do not have to pay back

                                 Name of Third Party: Teacher’s Benefactor Organization

= Total          $ 450.00        Remaining actual out-of-pocket expense.

X                75% (.75)

TOTAL           $ 337.75        Amount due from the Kentucky Teachers’ National
                                Certification Incentive Trust Fund

Print and attach a copy of your NBRIC statement from the NBPTS website
(www.nbpts.org).
I attest the above to be an accurate accounting of my National Board for Professional Teaching Standards
fees.

______________________________________ _______________________                _____________
Print name                             Social Security #                      Candidate #

______________________________________                      ___________________
Signature                                                   Date

Address___________________________________________________

        ____________________________________________________

Phone: _________________________ Email: _______________________________

RETURN TO:
Lynn Hines
NBPTS Program Manager
Western Kentucky University
1906 College Heights Blvd. #11030
Bowling Green, KY 42101

                              SAMPLE ONLY – DO NOT RETURN

								
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