PAC Expense Reimbursement Form: 
Reasonable travel to child's visitation or to remain in same school that child is attending at time of placement until transportation is attained.
Instructions: Expense reports must be submitted within 30 days after the end of the month in which travel occurred or payment will not be rendered (e.g. March expenses must be turned in by April 30). 
Employee Name: (Please Print)		
Street Address, City, State, Zip Code:		
Month/Year:		Location/Site & Phone or Contact #:		

Date	Purpose and Address start and end.	Tolls	Parking	Total Miles	Mileage
Rate .40	Other
Purchase	Total all
Columns	

				

								

								

								

								

								
								
Totals							

Date received at Supervisor/Program/Division Director's Office:		Printed Name of Person Confirming Receipt:		
Signature of Employee/Resource Parent (Required):	Date:		Date:	
Signature of Supervisor/Program Director/Division Director (Required):	Date:			
Signature of County Director/Administrator/Executive Director (If over $200):	Date:			
Signature of Fiscal Analyst (Required):	Date: