Form 9/30 CNCS - Disaster Deployment Reimbursement Request Form

Corporation for National & Community Service
Disaster Deployment Reimbursement Request Form
1. Recipient Organization (Name and complete address including zip code)
2. Invoice Point of Contact (Name, position title, telephone number, fax number and Email address)
3. Grant Number [OEM]	4. Mission Assignment Number	5. Mission Start Date	6. Mission End Date
7. Final Invoice?	8. Type of Activity and Location Served:	9. Invoice Start Date	10. Invoice End Date
11. Number of Enrolled Members/Participants	12. Location(s) Where Deployed	13. From Date	14. To Date
8
Reimbursement Claim
15. Transportation
a. Program-owned Vehicle(s) -- 730.37;
b. Rental Vehicle(s) -- 29,645.64
c. Rental Vehicle Fuel -- 6443.66;
d. Common Carrier
e. Other -- 682.60; 845.13; 826.02 [Personal Vehicle mileage charges]
f. Total Transportation Costs (15a + 15b + 15c + 15d + 15e plus additional lines if identified)		$0.00
16. Lodging
a. Commercial Lodging -- 4642.85; 220.01
b. Other Lodging -- 4474.58
c. Total Lodging (16a + 16b plus additional lines if identified)		$0.00
17. Food
a. Restaurant Meals -- 235.75; 130.51
b. Groceries/Cooking supplies -- 67.91;
c. Other Food
d. Total Food (17a + 17b + 17c plus additional lines if identified)		$0.00
18. Supplies
a. Durable Supplies (tools) -- 219.35;
b. Durable Supplies (non-tool)
c. Consumable Supplies -- 4867.38
d. Other Supplies
e. Total Supplies (18a + 18b + 18c+ 18d plus additional lines if identified)		$0.00
19. Communications
a. Field Communications -- 3851.04
b. Delivery and Shipping
c. Other Communications
d. Total Communications (19 a + 19b + 19c plus additional lines if identified)		$0.00
20. Other
a. Other costs not claimed above (identify) Personnel -- 41,232.28; 3878.07
b Other -- Locksmith 26.75; Volunteer Management Software 5000;
c. Total Other Costs (20a + 20b plus additional lines if identified)		$0.00
21. Grand Total Reimbursement Claimed (15f + 16c + 17d + 18e + 19d + 20b)		$0.00
Certification: I certify to the best of my knowledge and belief that this report is correct and complete and that all claims are for the purposes set forth in the award document(s) and are true and accurate to the best of my knowledge under penalty of law.
22. Name and Title of Authorized Certifying Official:		23. Telephone (Area code, number and extension)
		24. Email address
25. Signature of Authorized Certifying Official:		26. Date Request Submitted (Month, Day, Year)
CNCS DRAFT 9/30