RETAC Funds Reporting & Reimbursement Form for FY2017-2018
This form is used to submit purchases for reimbursement from the individual County or Prevention annual funds.
We are required to report how all of the State funds are spent at the county level every year. Please fill out the information below by May 11, 2018. Then send 100% proof of spending including receipts or backup materials to mikaela.greene@cmretac.org. Once we receive your receipts and this completed form, we will approve your spending report and reimburse your expenses. We plan on bringing all of the checks to the May Board Meeting.
Contact Information of person completing this form
Name *
Your answer
Agency *
Your answer
Title *
Your answer
Email *
Your answer
Phone Number *
Your answer
County
What county are you from? *
Required
Funds
What funds are you applying for? *
Required
Agency Participation
How have your agencies participated in the CMRETAC meetings and activities throughout the past year? Please list examples to prove participation. *
Your answer
15 EMTS System Components
Which of the 15 EMTS System Components are met with your spending? *
Required
Explain how your spending applies to what you selected above: *
Your answer
CMRETAC Biennial Plan Goals
Which of the 5 CMRETAC Biennial Goals are met with your spending? *
Required
Explain how your spending applies to what you selected above: *
Your answer
Value
Please describe the value your spending brought to your county. This includes data collection and outcomes (i.e. attendance, change in behavior, population impacted, number of classes, etc): *
Your answer
Expenses
List the expenses and amounts below: *
Your answer
Reimbursement
List who and where we should send the reimbursement check:
Name: *
Your answer
Agency *
Your answer
Title *
Your answer
Mailing Address *
Your answer
Email *
Your answer
Phone Number *
Your answer
THANK YOU!
Thank you for filling out the form and contributing to the health and safety of our region. Remember to send 100% proof of spending including receipts or backup materials to mikaela.greene@cmretac.org

Please let Anne or Mikaela know if you have any questions. Anne can be reached at anne.montera@cmretac.org and Mikaela can be reached at mikaela.greene@cmretac.org or by calling: 970-718-2742

Anne Montera Mikaela Greene
Executive Director Chief Communicator
Central Mountains RETAC

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