Exceptional Student Learning Support1701 NW 23rd Avenue

Fort Lauderdale, FL 33311 (754) 321-3466

Rev. 5/2018

CONFERENCE/WORKSHOP FINANCIAL ASSISTANCE (2018-2019) Complete and return via mail or email [lorraine.fritz@browardschools.com]

Date: School Board Employee: ❑ Yes ❑ No

Name: Email:

Phone: / / (home) (cell) (work)

Address: City Zip

Name of Child: Exceptionality:

Broward County School Child Attends:

Have you received funding from FDLRS within the last 12 months? Yes No

I am requesting financial assistance, up to $ , from FDLRS for the following conference: (attach copy(ies) of conference information)

Name of Conference: Date(s):

Location of Conference:

❑ My request may be shared with the ESE Advisory Council Executive Committee.

My anticipated expenses are: (Total Conference fees must not exceed $ 1,000.) TRAVEL

(mileage/transportation) LODGING**

(50 miles or more) REGISTRATION

FEE MISCELLANEOUS

(tolls, parking, etc.) CHILD CARE ($8/hr or $50

flat day rate) MEALS

(School Board Allowance)

Requests for reimbursement MUST be received within 2 weeks following the conference end date.

I am involved in the following activities: (check all that apply) ❑ ESE Advisory Council.

** (Lodging reimbursement – available if conference is 50 miles or more one way

from applicant’s home)

❑ School Advisory Council (SAC)/Parent-Teacher Association (PTA) /School Advisory Forum (SAF) Name of School

❑ Local/State member of parent support group/organization: Name of Organization

❑ School Volunteer

❑ Other:

Additional Information:

If funding is approved, I am willing to provide a brief overview of the conference/workshop at the ESE Advisory Council. I understand that failure to comply will result in lack of funding for future requests.

Requests must be received no later than one month prior to the event.

Applicant’s Signature/Social Security Number

Note: Please see attached document for additional information.

❑ Approved ❑ Not Approved ❑ Applicant Notified Date Date Date

Director, ESE FDLRS Coordinator

Financial Assistance Procedures PARENT ASSISTANCE

Pending the availability of grant funds, FDLRS/REACH provides financial support for families of students with disabilities within the Broward County Public School system to attend local, regional or state conferences and workshops that will foster and promote collaborative educational partnerships. Parent requests for assistance are limited to $1,000 per family within a school year. The Coordinating Council of FDLRS must approve all requests for funds. High consideration will be given to those parents who have not previously accessed funds. Priority will also be given to parents who are actively involved in one or more of the follow activities:

* ESE Advisory Council * Local/State Parent Support Group Organization* School Advisory Council/School Improvement Team/ * School Volunteer

Parent-Teacher Association

COMPLETING THE REQUEST FOR FINANCIAL ASSISTANCE FORM

� The request form must be completed in its entirety and submitted to the FDLRS Coordinator no later than one month prior to the event. � The request form must specify how funds will be utilized (e.g., travel mileage, transportation, hotel, registration fee, child care, etc). � Note: Lodging expenses will only be reimbursed if conference is more than 50 miles one way from applicant’s home. � A copy of the conference information MUST accompany the request. � A written summary of the conference/workshop activities must be provided using the FDLRS Conference/Workshop Report Form. Information

from this report may be shared in part or its entirety in the Education & Resource Guide for Parents or other family-centered publications. Parents are encouraged to also share their information with community-based support organizations.

� Reminder: Total conference fees must not exceed $1,000. Mileage and travel expenses are reimbursed at the Broward schools approved per diem rates. (Fuel is NOT reimbursed)

REQUEST NOTIFICATION The FDLRS Coordinator will notify applicant of the status of the request for assistance via a telephone call or written notice as soon as possible and no later than two weeks following receipt of request form.

CHILD CARE

Childcare expenses may be reimbursed at a rate of $8 per hour for a maximum of 6 hours or a flat rate of $50 for the day. An original receipt must accompany the reimbursement request.

MEALS

Meals may be reimbursed at a rate of $8 for breakfast, $11 for lunch and $20 for dinner. Reimbursements are for APPLICANT ONLY (not family traveling with applicant). Do not send meal receipts.

REIMBURSEMENT FOR NON SCHOOL BOARD EMPLOYEES To expedite the reimbursement process, please be sure to include the following items:

� Conference/Workshop Agenda � Original receipts for transportation, lodging, child care as appropriate � Mileage calculation � Conference/Workshop Report** � W9 � Expense Report

REIMBURSEMENT FOR SCHOOL BOARD EMPLOYEES To expedite the reimbursement process, please be sure to include the following items:

� Signed TDA � Travel Voucher � Conference/Workshop Agenda � Original receipts for transportation, lodging, child care as appropriate � Mileage calculation � Conference/Workshop Report**

Requests for reimbursement MUST be received within 2 weeks following the conference end date.

**Reimbursement will not be processed until Conference/Workshop Report form is received.

Rev. 5/2018

Exceptional Student Education & Support Services 1701 NW 23rd Avenue

Fort Lauderdale, FL 33311 (754) 321-3466

Rev. 5/2018

Conference /Workshop Report

Name: Date:

The following is a summary of my trip to: City & State

on: for: Date(s) Conference/ Workshop

Highlights of Sessions Attended & “Lessons Learned”

1. Describe what you learned by attending a specific conference/workshop session. (Include title of the session and related information thatwould be beneficial to other parents.)

2. List names and contact information of helpful resource information, that other parents may want to order or access (i.e. names ofresource/contact persons, title of books or journal/magazine articles, website addresses, etc).

3. Suggestions for how other parents may apply the information you learned from attending the conference/workshop.

4. List any other pertinent information you wish to share related to your trip.

Note: I understand this information and my name will be posted on the Exceptional Student Education website(under ESE Parent Workshops), to foster the sharing of information with other parents of students with disabilities.

Form W-9 (Rev. October 2007) Department of the Treasury Internal Revenue Service

Request for Taxpayer Identification Number and Certification

Give form to the requester. Do not send to the IRS.

Prin

t or

type

See

Spe

cific

Inst

ruct

ions

on

page

2. Name (as shown on your income tax return)

Business name, if different from above

Check appropriate box: Individual/Sole proprietor Corporation Partnership Limited liability company. Enter the tax classification (D=disregarded entity, C=corporation, P=partnership) �

Other (see instructions) �

Exempt payee

Address (number, street, and apt. or suite no.) Requester’s name and address (optional)

City, state, and ZIP code

List account number(s) here (optional)

Part I Taxpayer Identification Number (TIN)

Enter your TIN in the appropriate box. The TIN provided must match the name given on Line 1 to avoid backup withholding. For individuals, this is your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3.

Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose number to enter.

Social security number

or Employer identification number

Part II Certification Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal

Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS hasnotified me that I am no longer subject to backup withholding, and

3. I am a U.S. citizen or other U.S. person (defined below).Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the Certification, but you must provide your correct TIN. See the instructions on page 4.

Sign Here

Signature of U.S. person � Date �

General Instructions Section references are to the Internal Revenue Code unless otherwise noted.

Purpose of Form A person who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) to report, for example, income paid to you, real estate transactions, mortgage interest you paid, acquisition or abandonment of secured property, cancellation of debt, or contributions you made to an IRA.

Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN to the person requesting it (the requester) and, when applicable, to:

1. Certify that the TIN you are giving is correct (or you arewaiting for a number to be issued),

2. Certify that you are not subject to backup withholding, or3. Claim exemption from backup withholding if you are a U.S.

exempt payee. If applicable, you are also certifying that as a U.S. person, your allocable share of any partnership income from a U.S. trade or business is not subject to the withholding tax on foreign partners’ share of effectively connected income. Note. If a requester gives you a form other than Form W-9 to request your TIN, you must use the requester’s form if it is substantially similar to this Form W-9.

Definition of a U.S. person. For federal tax purposes, you are considered a U.S. person if you are: � An individual who is a U.S. citizen or U.S. resident alien, � A partnership, corporation, company, or association created or organized in the United States or under the laws of the United States, � An estate (other than a foreign estate), or � A domestic trust (as defined in Regulations section 301.7701-7). Special rules for partnerships. Partnerships that conduct a trade or business in the United States are generally required to pay a withholding tax on any foreign partners’ share of income from such business. Further, in certain cases where a Form W-9 has not been received, a partnership is required to presume that a partner is a foreign person, and pay the withholding tax. Therefore, if you are a U.S. person that is a partner in a partnership conducting a trade or business in the United States, provide Form W-9 to the partnership to establish your U.S. status and avoid withholding on your share of partnership income.

The person who gives Form W-9 to the partnership for purposes of establishing its U.S. status and avoiding withholding on its allocable share of net income from the partnership conducting a trade or business in the United States is in the following cases: � The U.S. owner of a disregarded entity and not the entity,

Cat. No. 10231X

Private Car Mileage ( miles x cents per mile)* $ Place/Common Carrier (attach ticket stub)

Rental Car (attach rental contract) Taxi Limousine P ar king (attach receipts)

Food (Class C Only) Hotel (Class C Only)

A/P Document Number

EXPENSE VOUCHER (Non-county personnel) The School Board of Broward County, Florida VENDOR

NUMBER

Date Name

Social Security Number:

Address:

COMPLETE APPLICABLE SECTIONS - ATTACH A COPY OF THE CONSULTANT AGREEMENT SEND APPROVED DOCUMENTS TO ACCOUNTS PAYABLE.

I. PURPOSE OF TRIP:

II. TRANSPORTATION:

*Current rate as published in the most recent memorandum from the Treasurer’s Office.

III. PER DIEM:Computed by quarters: days x *

*Current rate as published in the most recent memorandum from the Treasurer’s Office.

Departed from Home A.M. P.M. , 20

Returned to Home A.M. P.M. , 20

Total Of Sections II, III = Total Of Expense Voucher $

IV. AUTHORIZATION:I hereby certify that the above claim is just and true in all respects, that it conforms with the requirements of School Board Policy, and that payment therefore has not been received.

Approval Principal/Department Head Signature of requesting person

V. EXPENDITURE INFORMATION: Check

Request No.

Gross Amount

G/L Account (8)

Class+Obj+0’s

Bus Area (4)

Cost Center (10)

BA+T+L+0

Fund (4)

Internal Order (12)

WBS Element Capital Use

Grant (14)

Functional Area (16) Function + Activity

+0’s

Form 3044A (Rev 11/07)

.545

Tolls