REQUEST FOR REIMBURSEMENT FORM

Name

First Name

Last Name

Date

Email Address

Website

http://

Home Phone

(###)

###

####

Other Phone

(###)

###

####

Place (School) You Served As Artistic In Residence

School District

Dates Of Sessions

Number Of Students With Disabilities

Total Number Of Students

Amount Of Reimbursement

X $65.00 Per Hour

Total Number Of Hours

Total Number Of Hours x $65.00

Round Trip Mileage

Round Trip Mileage x 55¢ per mile

Teaching Artist Fee

Travel Allowance

Supplies (Attach Receipts)

Total

I certify that I have incurred these expenses and performed these services as a Teaching Artist for Art For All Mississippi.

Type in your name as certification