Attachment D
(Original Required)COMMONWEALTH OF VIRGINIA
Department of Education
Office of Career, Technical, and Adult Education
P.O. Box 2120
Richmond, VA 23218-2120
VIRGINIA CYBERCAMP 2017
STATE FUNDING ALLOCATION EXPENDITURES REPORT
School Division No.:
School Division Name:
Reimbursement No. / 1 2 3 4 5
Documentation in this report is submitted to support Virginia CyberCamp 2017 state-funded expenditures submitted in the application.
CERTIFICATION: I certify to the best of my knowledge and belief that the reimbursement is true, complete, and accurate, and the expenditures and disbursements are for the purposes and objectives set forth in the terms and conditions of the State funding allocation. I am aware that any false, fictitious, or fraudulent information, or the omission of any material fact, may subject me to criminal, civil or administrative penalties for fraud, false statements, false claims or otherwise. I further certify that documentation has been retained in the office of the educational agency/organization and is available upon request to support the claim. It is understood that this claim is subject to federal and/or state audits. By submitting and approving this request, the educational agency/organization submitter and approver(s) acknowledge the certification and agree to its provisions.
Virginia CyberCamp 2017 / Amount
State Allocation Funds Payment(s) Received:
$
Total Amount Claimed: / $
Preparer’s Name: / Preparer’s Email:
Preparer’s Telephone No: / Preparer’s Fax No:
Date / Virginia CyberCamp 2017 - Director's Signature
Date / Division Superintendent’s or Authorized Signature
(All Signatures must be in BLUE INK)
------For Department of Education Use Only------
STATE ALLOCATION FUNDS
Payment Amount(s): / $ / Payment Date(s):
Project Code: / State APE60308 / Voucher Number(s):
If you have any questions, please contact CTE Grants Manager at (804) 225-2052 or .
Submit the completed/signed forms by October 16, 2017 to: Virginia Department of Education, Office of Career, Technical, and Adult Education, Attn: CTE Grants Manager, or P.O. Box 2120, Richmond, VA 23218-2120 or scan/fax/email a PDF version in color to: (804) 530-4560.
Attachment D
Page One
(Original Required)
VIRGINIA DEPARTMENT OF EDUCATION
Office of Career, Technical, and Adult Education
Virginia CyberCamp 2017
STATE-FUNDED ALLOCATION BUDGET AND EXPENDITURES LEDGER
School Division Number:Name: / Name:
(1)
Expenditure
Accounts / (2)
Object
Code / (3)
State Allocation Budget / (4)
Expenditures
For State Allocation / (5)
STATE ALLOCATION
BALANCE
(Col. 3 Less Col. 4)
Personal Services / 1000
Employee Benefits / 2000
Purchased Services / 3000
Internal Services / 4000
Other Services / 5000
Materials/Supplies / 6000
TOTAL
NOTE: FORM MUST BE COMPLETED AND SUBMITTED TO THE VIRGINIA DEPARTMENT OF EDUCATION WITH FINAL VIRGINIA CYBERCAMP 2017 EXPENDITURES REPORT BY OCTOBER 16, 2017.
Page Two
(Original Required)
VIRGINIA DEPARTMENT OF EDUCATION
Office of Career, Technical, and Adult Education
Virginia CyberCamp 2017
ALLOCATION EXPENDITURES LEDGER
School Division Number: / Name:This form is to be used to document expenditures for Object Codes 1000, 2000, 3000, 4000, 5000, and 6000.
DO NOT SUBMIT ANY COPIES OF RECEIPTS, VOUCHERS, ETC.
ALL INFORMATION MUST BE PROVIDED
Vendor / Item Description / Object Code / Check or Voucher No. / Date of Payment / Amount
TOTAL- $
NOTE: FORM MUST BE COMPLETED AND SUBMITTED TO THE VIRGINIA DEPARTMENT OF EDUCATION WITH FINAL VIRGINIA CYBERCAMP 2017 EXPENDITURES REPORT BY OCTOBER 16, 2017.