Private & Parochial Schools in Madison Metropolitan School District

Title II Service Agreement Request Form

DIRECTIONS: Service Agreements can take up to two months to process. Please plan ahead as we need to have service agreements approved before work can be completed. All service agreements are written between MMSD, Vendor and Private and Parochial School. If there is not sufficient Title II funding to cover the vendor’s full cost of service and expenses, Private and Parochial School will be responsible for the outstanding balance.

1)Private and Parochial Administrator should complete and sign this Service Agreement Request form. Please print legibly.

2)Forward the signedService AgreementRequest form to Stephanie Dankert, at MMSD. Please allow two weeks for processing.Approval of this form only indicates that this request is allowable under Title II Funding. We will not ensure payment until: theconsultant’s service agreement is approved by MMSD, the work meets Private and Parochial school’s needs assessmentand Title II funds are available. If any of this criteria is not met, payment will become the responsibility of the Private and Parochial school where work was performed.

3)A Service AgreementForm is then sent directly to the Consultant from MMSD.Ifconsultant is new, they must complete a W-9 form. Both forms should be completed and forwarded to Melissa Ohm at MMSD.Approval can take up to an additional month.

4)7- 10 days after the work is complete the consultant should invoice MMSD.Final invoices for current school year must be received by June 30, in order to be paid out of the current year’s grant funds. Any late invoices will become the responsibility of the Private and Parochial School. We cannot pay with Title II grant funds after the end of the school year in which the work was performed.

Melissa Ohm Contact Info: State and Federal Prog. Rm 124, Madison Metropolitan School District, 545 W. Dayton Street, Madison, WI 53703 or e-mail or fax to:608-442-2160

Name of Private and Parochial (P/P) School:
P/P Contact
Name: / Contact E-mail: / Contact
Phone:
Detailed Description of Provider’s Service
Start Date of Activity: / End Date of Activity: / Location of Activity:
Rationale for Attendance which must be linked to School’s Needs Assessment:
Detailed Cost of Service: (amount per hour or per day)
Example: $100/day for 10 days. / Describe additional expenses (registration, meals, mileage, supplies etc.) / Total Amount of Contract:
Administrator’s Signature: / Date:
Consultant/Vendor Information
Full Legal Business Name: / Contact Name:
E-mail / Phone:

MMSD Office Use Only

MMSD Title II Approval: / Date:
Date Service Agreement Request Received: / Date Entered: / Date Approval forwarded to requester:
Date Service Agreement Form forwarded to Vendor: / Date Service Agreement Approved by MMSD: / Date Invoice Received:
If new vendor, W9 Date
W-9 Received and Entered: / Vendor #
Fund / Org / Object / Function / DPI Project / Local B / Location / Project / Amount
Title II Account #: / $