/ Florida State Referees, Inc. Expense Reimbursement /

Florida State Referees, Inc.

6671 W. Indiantown Road Suite 50-305
Jupiter Florida 33458-3984
E-mail:

All expenses must be submitted within 30 days after expense.

Name:
Address: / TOTAL CLAIMED:
(with mileage when applicable) / $ total duewith mileage
City:
State: Zip:
Phone: ()- / TOTAL PAID: / $ total duewith mileageWith out mileage
(leave blank - FSR use only)
Signature:
Date Submitted: / e-mail address:
GENERAL EXPENSES
NOTE: NO REIMBURSEMENTS WILL BE MADE WHEN NOT PRE-AUTHORIZED OR WITHOUT RECEIPT.
Telephone:
(designate names on bill) / $ / Postage/Shipping
Requires the receipts / $ / Course # (Required) : (district course # mm yy) / A1A2A3A4A5A6A7B1B2B3B4B5C1C2C3C4C5C6D1D2D3D4- 0123456789 0123456789- 010203040506070809101112 12131415-
(clear through FSR office first) Any Printing/Copying: / $ / (clear through FSR office first)
All Supplies:$ / All Other:
(clear through FSR office first) Explain in the Remarks below* / $
Administrator Fee due: / $ Your job as Administrator: Special fee$35.00 Timer$100 Admin fee R08 re-cert$150 Admin fee - New Open + Close Cass$75 Admin fee - Open New Class$75 Admin fee - Close New Class$175 Admin 08 to 07 course$200 Admin 07 to 06 course$200 Admin fee 05 State re-cert
TRAVEL EXPENSES
NOTE: NO mileage will be paid for less than 50 miles one way.
ALL SPECIAL TRAVEL CIRCUMSTANCES MUST BE CLEARED THROUGH FSR OFFICE PRIOR TO SUBMITTING FORM
Attach Receipts For All Expenditures.
From (city): / To (city):
Date(s): / From:To: / Purpose:
Airfare: / $ Requires the receipts / Lodging: / $ Requires the receipts
Parking: / $ Requires the receipts / Tolls: / $ Requires the receipts
Per Diem due: / 12345678910 days x $ 355075100125150180200 = $ 35507075100105140150175200210225245250280300315350375385400450500525 / Other: (explain)* / $ Requires the receipts
Mileage due? Yes No (deducting local 100 miles when applicable - computed city to city only) / Total miles*
Explain special mileage circumstances in the remarks section below if additional mileage is due over and above the normal formula. *
MENTOR or ASSESSMENT EXPENSES
Host Club: / Assigned by:
Tourney Name: / Date:
Mentor/Assessor # ofhours 012345678910 x $ 355075100125150180200250300350400 = $ 35507075100105140150175200210225245250280300315350375385400450500525
INSTRUCTION EXPENSES
Host Club: / Assigned by:
Course # (Required):
(district course # mm yy) / A1A2A3A4A5A6A7B1B2B3B4B5C1C2C3C4C5C6D1D2D3D4- 0123456789 0123456789- 010203040506070809101112 12131415: Recert 08-09-12Recert 07-06-05Entry 08Entry 09Entry 12Upgrade 09 to 08Upgrade 08 to 07Upgrade 07 to 06Assessor RecertAssoc. AssessorInstructor RecertState AssessorAssoc. InstructorInstructor ITIPAssignor entryAssignor recertPro ClinicTimerLecture or tournament
Course Fee due: / Your job as Instructor Special course feeR08 Re-cert = $100.00 All level of instructorsGrade 09 Instructor Fee = $20.00 HRGrade 07 Instructor Fee = $25.00 HRGrade 05 State Instructor Fee = $30.00 HRGrade 03 National Instructor Fee = $30.00 HR05 Re-cert 5HR = $150.00 State InstructorsAR Re-cert 5HR = $150.00IR Re-cert 5HR = $150.00$50.00 Instructor Observation $
# hours on podium: / 123456789101112131415161718192021222324 / As Lead instructor Associate instructor Assistant (special courses)
All Instructors are required to record podium hours of instruction online before payment will be made.
Remarks:*
For Office Use Only:
Approved by: / Dated: / Paid ck # Dated:

Confidential Page 1 10/2/2013 Version