Washington-Saratoga-Warren-Hamilton Essex Counties

Washington-Saratoga-Warren-Hamilton Essex Counties

Board of Cooperative Educational Services

1153 Burgoyne Avenue, Suite2

Fort Edward, NY 12828

SPECIAL PROJECT AGREEMENT

Service Provider: ______

(Type or Print)

Address: ______

______

Telephone Number: ( ) Fed ID #: ______

Fax Number: ( )______

I hereby agree to provide the following service for the Washington-Saratoga-Warren-Hamilton-Essex Counties BOCES:

Description of Service: ______

______

Location: ______

Date(s): ______Time: ______

Stipend: ______

It is understood that stipends are subject to certain regulations set forth by the Internal Revenue Service and will be reported accordingly at the end of each calendar year.

Other Expenses: (Estimated)

Travel: @______cents per mile Est. # of miles: ______

Lodging: ______$ ______

Other: (please specify) ______

Special Conditions/Equipment: ______

______

Date: ______

(Service Provider)

BOCES Personnel Use Only Total Estimated Cost: $______

SOURCE OF FUNDING:

General Fund Budget Code: ______

Special Aid Fund Code: ______

Project: ______

Approval: ______Date: ______

(Director/Supervisor)

White – Business Office Canary – Program Office Pink – Program Office Gold – Service Provider

8/2012