3 Deployment Reimbursement Form

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Overview

Reimbursement Form
Additional Breakdown

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Sheet 1: Reimbursement Form

Disaster Deployment Reimbursement Request
1. Program Name:		2. Point of Contact (Name, Email, Phone)			3. Type of Activity and Location Served:
4. Date Submitted	5. CAM1 (Completed by DSU)		6. Mission Assignment Number: (Completed by DSU)		7. MA Start Date (Completed by DSU)	8. MA End Date (Completed by DSU)	9. Invoice Start Date (Must be on or after MA start date)	10. Invoice End Date (Must be on or before MA end date)
Directions: Please complete with actual allowable costs incurred. Include detail and rates were applicable. If entering more items than the provided lines in any section, use the Additional Breakdown sheet provided and transfer the total to the appropriate section. Please note that there are formulas built into the sheet to compute the total automatically.
Travel			Personnel
a. Transportation			Type (Lost FFS for AmeriCorps members, Staff OT, etc.). Please include formula(s) for any personnel costs:				Cost
Type (airfare, train, rental car, etc.)	Cost
Subtotal Transportation		$-
b. Lodging (Include rate/# members/days)			Total Personnel					$-
Type (hotel, volunteer housing, etc.)	Cost		Supplies
			Description (PPE, approved tools, etc.)				Cost
Subtotal Lodging		$-
c. Subsistence
Type (groceries; restaurant; vol. housing,etc)	Cost		Total Supplies					$-
			Other Operating Expenses
			Description (Phone costs, fuel for equipment, etc.)				Cost
Subtotal Food		$-
d. Laundry
Type (laundromat charges, etc.)	Cost
			Total Equipment					$-
			Other Miscellaneous Expenses
Subtotal Laundry		$-	Description				Cost
e. Other Travel
Type (tolls, parking, gas, luggage fees, etc.)	Cost
			Total Other					$-
Subtotal Other Travel		$-	Total Reimbursement Request					$-
Total Travel		$-
AmeriCorps Approvals: Sign and Date
Disaster Services Unit:		CFO Office:			Office of Grant Administration:

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Sheet 2: Additional Breakdown

AmeriCorps Disaster Deployment Reimbursement Request: Additional Breakdown
Program:	0
Mission Assignment Number:
Invoice Dates:
Travel
Transportation
Type (airfare, train, rental car, etc.)	Cost
Subtotal-Transportation	$-
Lodging (Include rate/# members/days)
Type (hotel, volunteer facility, etc.)	Cost
Subtotal-Lodging	$-
Subsistence
Type (groceries/self-prepared; restaurant; volunteer facility)	Cost
Subtotal-Food	$-
Laundry
Type (Laundromat charges, etc.)	Cost
Subtotal-Laundry	$-
Other Travel
Type (Tolls, Parking, etc.)	Cost
Subtotal-Other Travel	$-
TOTAL TRAVEL		$-
Personnel
Reminder: MA covers only additional personnel costs incurred outside of normal spending. Please include formula(s) for any personnel costs:
Type (Lost FFS for AmeriCorps members, Staff OT, etc.).	Cost
TOTAL PERSONNEL		$-
Supplies
Description and Quantity (PPE, approved tools, etc.)	Cost
TOTAL SUPPLIES		$-
Other Operating Expenses
Description and Quantity (Phone costs, fuel for equipment, etc.)	Cost
TOTAL EQUIPMENT		$-
Other Miscellaneous Expenses
Description and Quantity	Cost
TOTAL OTHER		$-
TOTAL Reimbursement		$-