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Staff Reimbursement Form
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Original Date Attach
Name
*
First
Last
Date of Expenditure
*
Type of Expenditure / Reason:
*
1:1 Resident Name (If Applicable)
*
First
Last
Amount
*
Staff Signature
*
Clear Signature
Date Form Submitted to Day Program
Attach Original Receipt Here
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Receipt must be returned within 20 days for reimbursement.
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