Name: Identify the Client (Name / Ejas Number

Section A Request:

Name: Identify the client (name / eJAS number

Description: highly detailed description of goods to be purchased. Also, specify the goods which are excluded. For example, only goods which are for the use of the client will be reimbursed.

Justification: Reason for purchase which complies with scope of program goals

Amount:

The client must return the original sales receipt for the purchase.

The items on the sales receipt must correspond with the pre-request description.

There must be no co-mingling of support service item categories on the receipt. For example, hygiene products, clothing, and diapers must be on separate receipts.

The amount reimbursed will not exceed the maximum amount of the pre-request.

The date of the final, original receipt must be after the date of the approval signature by the supervisor.

The client will have 14 days past the day the supervisor approves the pre-request to submit the final, original receipts for reimbursement. If the receipt is presented after the 14 day period, the reimbursement will not be granted because the client had violated the terms of the agreement and therefore voided the agreement.

The client must sign that they understand the conditions that will determine their reimbursement.

Also, the client must remain enrolled in the program and NOT have been exited before the reimbursement check has been created. If the client finds employment, then they will have a 14 day grace period past that employment date that the reimbursement check may be generated.

Section B Recommendation:

Completed by the Case Manager for the maximum limit for the request

Signature required.

Section C Authorization:

Completed by the Program Director to determine the amount approved - full or adjusted amount

Signature required.

The accounting department is involved when the case manager returns with an original sales receipt that meets all of the conditions of the pre-request. Once they bring this receipt, the support service request form will be completed and the pre-request will be one of the support documents accompanying it.

The client will NOT be reimbursed if they do not submit the final original sales receipt. The client will not be reimbursed if only a re-print or a photocopy or duplicate of the original receipt is submitted. Only original receipts may be accepted so that the client may not return the articles for a refund.If unauthorized items are included on the final sales receipt, the client will not be reimbursed for those expenditures. The client will not be reimbursed if they have been exited from the program. The client will not be reimbursed if they have found employment and they are outside the 14 day grace period outside the employment date. The client will not be reimbursed if they do not return original, final sales receipts within 14 days of the program supervisor’s approval signature.

The client will be set up in QB as a ‘Vendor’ for approved expense reimbursements payments and W9’s are not required.