Fund Reimbursement/Utilization Request Form

Submit completed forms to Melissa Thompson at


Division:         Choose an item.





Request Date:

Section I: Request Details (To be completed by the requesting school division)

Choose an item. is requesting reimbursement and/or utilization of funds, in the amount specified below, from the Piedmont Regional Education Program (PREP) from the following account:


Medicaid Reimbursement Carryover: $


Section II: Request Confirmation (To be completed by PREP Finance Specialist)

Request processed as outlined above:

Former carryover account balance: $_________/New carryover account balance: $___________


Unable to process request as written.

             Rationale: ________________________________________________________




Finance Specialist Certification:





Executive Director Certification: