New Claim Voucher and Reimbursement Instructions This form is required to receive payment from the state. It must be submitted in ink with the payroll report. Claimant’s Name This should be pre-printed. If you are using a blank form, it must be copied on to white paper, and in the new format. Fill in the name of the employer as you would like the check to read. Fill in your mailing address. Do not list the name of any individual on the first line. Social Security Number Please leave blank. No individual social security numbers are needed on this form. Federal I.D. Number This should be pre-printed from the information submitted Tosco on the W-9 form. If you are using a blank form, use your Taxpayer Identification Number (TIN). If you do not have a TIN, refer to the W-9 form for instructions. State Agency Fill In (Body of form) To save time in obtaining your signature on this form, we must ask you to submit this form with amounts filled in. There are two places where the amounts must be entered. These amounts must agree with the figures on the payroll report.
**New Information** Please fill in the month(s) for which expenses are being claimed in the Service Date(s) field which is highlighted in yellow.
This form must be signed in ink and dated by an authorized representative of your agency at the bottom of the form, where it says “Signature of Vendor”. (Make a copy of the claim voucher for your records.) Claiming Funds ( Please note the new policy when claiming funds) Send both the original payroll report and white claim voucher to SSACI for payment. PLEASE NOTE: When submitting more than One Payroll Report, please combine all totals from the payroll reports, and Submit only (1) Claim Voucher for the combined payroll reports. Upon receipt: the reimbursement will be made by Electronic Funds Transfer (EFT). In order to be reimbursed in a timely manner, The State of Indiana is required to have on file: An Automatic Direct Deposit Authorization Agreement and a Taxpayer Identification Number Request. These forms must be properly completed and mailed to our office before reimbursements are made. Copies of the forms are on the Employer Website at www.ssaci.in.gov/wse - click on printable forms. For Questions – Call the Summer Work Study Contact Person – Tina Humphrey State Student Assistance Commission of Indiana 150 W. Market Street - Fifth Floor Indianapolis, IN 46204-1088 (317) 232-2350 Timetable January - February -Employer Request Form distributed. January - March -Listings of eligible students distributed. -Listings of prospective employers available to students. February 1 -Deadline for Employers Requests to be postmarked. Spring Break -Good time to interview students. Mid-April -Announcements of Allotments. (or as soon as the legislature ends) Mid-to-Late-April -Official list of employers distributed to students, (via financial aid offices and student employment office, news releases). May 1 -Students may begin work. -Employer Agreements are returned to SSACI as soon as possible. -Accept or decline response must be returned to SSACI, or as soon as students begin work. September 15 -Last day students may work. October 15 -All claim vouchers must be submitted to SSACI November 1 -Annual Report due to SSACI (a copy will be mailed in late summer). Employer’s Fiscal -State Board of Accounts forms due for not-for-profit employers within 30 Year Ending days of their fiscal year.