Western Dubuque County Community School District
Student Travel Reimbursement Form
2/17/2019
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SECTION I: FOR ADMIN. OFFICE USE ONLY:

Vendor #:
Expense Acct. #:
Total Miles:
Total Reimbursement:
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SECTION II: PARENT/GUARDIAN COMPLETES:

  • Claims for reimbursement must be submitted on a monthly basis and approved by the building principal.
  • Reimbursement is at 50% of the IRS approved rate.
  • Payments will be issued within 10 days of the end of the month.
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Parent/Guardian First Name
*
Parent/Guardian Last Name
*
Student First Name
*
Student Last Name
*
Address
*
City
*
State
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Zip
*
Course name
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Cascade HS to WDHS = 14 miles (28 round-trip); Cascade HS to NICC = 17 miles (34 round-trip); Cascade HS to Kirkwood (Monticello) = 13 miles (26 round-trip); Cascade HS to Dubuque Hempstead or Senior = 27 miles (54 round-trip)


Date (mm/dd/yyyy)

Student traveled FROM this school building

Student traveled TO this school building

Miles Traveled

Date (mm/dd/yyyy)

Student traveled FROM this school building

Student traveled TO this school building

Miles Traveled

Date (mm/dd/yyyy)

Student traveled FROM this school building

Student traveled TO this school building

Miles Traveled

Date (mm/dd/yyyy)

Student traveled FROM this school building

Student traveled TO this school building

Miles Traveled

Date (mm/dd/yyyy)

Student traveled FROM this school building

Student traveled TO this school building

Miles Traveled

Date (mm/dd/yyyy)

Student traveled FROM this school building

Student traveled TO this school building

Miles Traveled

Date (mm/dd/yyyy)

Student traveled FROM this school building

Student traveled TO this school building

Miles Traveled

Date (mm/dd/yyyy)

Student traveled FROM this school building

Student traveled TO this school building

Miles Traveled

Date (mm/dd/yyyy)

Student traveled FROM this school building

Student traveled TO this school building

Miles Traveled

Date (mm/dd/yyyy)

Student traveled FROM this school building

Student traveled TO this school building

Miles Traveled

Date (mm/dd/yyyy)

Student traveled FROM this school building

Student traveled TO this school building

Miles Traveled

Date (mm/dd/yyyy)

Student traveled FROM this school building

Student traveled TO this school building

Miles Traveled
. .
I certify the above travel expenses were incurred to attend school courses and should be paid from district funds.
. .
*
Parent/Guardian signature (typed is sufficient)
*
Date (mm/dd/yyyy)
Routing Instructions
Please route this form to the following personnel:
1. Building Principal
2. Business Manager
Complete the information below to route your form. * Indicates Required Fields
Send to Approver:  
No approver has been assigned to this form, please contact your District Forms Manager.