SUBMIT ORIGINAL ONLY NO LATER THAN THE NEXT DAY FOLLOWING THE LAST POSSIBLE WORKDAY IN THE PAYROLL

PERIOD.

ADULT EDUCATION AND SKILLS TRAINING IN-SERVICE CLAIM FORM

revised 2/11/2013

Name Month and Year

Jane Hughes

Date of Training

Type of Training (Check one) Conf PreLocal Wrkshp Other Service In-Srvc

Session Title Description of Training/ Presenter

Times From 0:00 0:00 0:00 0:00 0:00 0:00 0:00 0:00 0:00 0:00 0:00 0:00 0:00 To 0:00 0:00 0:00 0:00 0:00 0:00 0:00 0:00 0:00 0:00 0:00 0:00 0:00 Total Hrs 0 0 0 0 0 0 0 0 0 0 0 0 0

Total Hours for Month Hours

* Rate

$0.00 Total

FICA Total $0.00 $0.00

Date I certify that I have not performed other duties at the same time I have been working in the adult education program as indicated above. I have not received and will not request compensation for performing another job during the hours for which I am requesting compensation through the adult education program. Participant Signature

Director Signature

indicated above. I have not received and will not request compensation for performing another job during the hours for which I am requesting compensation through the adult education program.