In-kind Cash Match Report Form by yoursovain

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									                                                                                                      2/26/2009

          Continuum of Library Education

                                             Reimbursement Form
Name:                                                           Institution:
Address:                                                            Phone:
                                                                      Fax:
                                                                     Email:



Expenses
Compensation Rate = Actual hourly salary plus fringe benefits

 Date            Name & Description of Task                                                   Total




                                                                               Grand Total:



I certify that this statement is accurate for the actual expenses that were incurred by me.
Signature:                                                                           Date:
Mail this form and all original receipts to:
Western Council of State Libraries Fiscal Officer, BCR
14394 East Evans Avenue; Aurora, CO 80014-1478
Phone: (303) 751-6277; Fax: (303) 751-9787

								
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