CNCS Disaster Response Cooperative Agreement

Disaster Deployment Reimbursement Request Form

USER INSTRUCTIONS

Please type or print legibly, and add additional rows as necessary in Sections 15 – 20 [doing so may expand the form onto a second page]. Claims for reimbursement of disaster deployment costs must be submitted no later than 30 days after the approved deployment period ends. A separate invoice should be submitted for each deployment for which reimbursement is requested. Every invoice must be signed and dated by an individual with authority to submit claims on behalf of the grantee.

Your program is responsible for maintaining documentation to support requested reimbursement, per requirements.

Item Entry Item Entry .

Self-explanatory. Contact person to respond to questions concerning items in invoice submission. Enter the Deployment Grant Number entered by CNCS Office of Emergency Management on your approved Deployment Summary Form. FEMA Mission Assignment Number Deployment Start Date Deployment End Date Indicate if this is your final total reimbursement request for this deployment (Yes), or an interim reimbursement request (No) to capture initial expenditures. Enter the type of disaster and deployment location. [e.g. Tornadoes – Kansas]. 9/10 If invoice covers a period for less than the entire deployment period, enter dates for which reimbursement is requested. 11/14 Enter number of deployed members by dates and locations during deployment 15. Transportation Costs. 15a. Program owned vehicles: Identify # of vehicles, total mileage 15b. Rental Vehicle(s): Identify # of vehicles, dates of rental. 15c. Self-explanatory 15d. Common Carrier: Identify # of travelers, dates of travel, mode [airline, bus, etc.] 15e. Other transportation costs not delineated in 15 a-d. 16a/b. Lodging Costs. Identify by # of members/staff, and # of nights in commercial and other lodging [campgrounds, universities, private homes, etc.). 17. Food Costs. 17a. Self-explanatory. 17b. Self-explanatory. 17c. Other Food Costs [e.g, payment for group meals provided]

18. Supplies Cost. 18a. Durable Supplies (tools) includes tools, tool parts, repairs and operation. 18b. Durable Supplies (non-tools) includes ice chests, tents, and similar items. 18c. Consumable Supplies such as duct tape, hardware, roofing supplies, computer supplies, office supplies and similar items. 18d. Other costs not delineated above. 19. Communications Costs. 19a. Identify number of instruments [cell phones, Blackberries, GPS units, etc.] and number of days used. 19b/19c Self-explanatory. 20. Other Cost Categories. 20a/b. Include on separate lines other cost categories of costs approved in your deployment budget. 21. Grand Total Reimbursement Claimed. Add lines 15 – 20. 22. Name of Authorized Certifying Official. 23/24. Contact Information 25. Original signature in ink with date. You may transmit the Invoice by e-mail, but you must also submit a signed copy. 26. Date of submission

Disaster Deployment Reimbursement Request Form – CNCS 9/30