Fund Reimbursement/Utilization Request Form

Submit completed forms to Melissa Thompson at mthompson3@k12albemarle.org

Division: Choose an item.

Requester:

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: ________________________________________________________

Date:

Finance Specialist Certification:

Date:

Executive Director Certification: