2023.01.12 VOCA-Reimbursement-Form.Final_.xlsx

	A	B	C	D	E
1	VOCA Financial Reimbursement Request Form
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3	To:	Office of the Attorney General
4	Attention:	Department of Administration (DOA), Division of Accounts
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6	VOCA Program (Subgrantee):
7	Mailing Address:
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10	Grant Award Number:			Vendor #:
11	Invoice #:			Contract #:
12	Invoice Date:			Account #:
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14	Period Claiming:	From:		To:
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16	Final Claim:	Yes:		No:
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18	Data Universal Numbering System (DUNS) No.:
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20	Total Grant Awarded:		For OAG Federal Grant Section Review ONLY
21	Less Previously Requested:				Adjustment to Invoice
22	Sub-total:	$ -	Amount Invoiced:
23	Less Amount of This Request:		Less Disallowed Costs:
24	Grant Balance:	$ -	Amount to be Paid:		$ -
25				OAG Official - (Initial/Date):
26	Certification: I hereby certify that this report represents a complete and correct accounting of the grant funds and that all expenditures herein listed are for purposes set forth and approved in the Grant award, necessary for victim services and reimbursement therefore is hereby approved.
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31	Agency Certifying Official:
32		Print Name and Sign			Date
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34	Program Director:
35		Print Name and Sign			Date
36
37	- Below for Official Use Only -
38	Reviewed for compliance with VOCA Grant contract and Guidelines:
39	__________________________________________________________________________
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41	VOCA Administrator				Date
42	Approved by: ___________________________________________________________
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44	Douglas B. Moylan, Attorney General				Date
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46	REPLENISHMENT REPORT
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50	VOCA Program (Subgrantee):
51	Grant Award Number:
52	Period Claiming:	From:		To:
53	Prepared By:
54	Approved By:
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56	OBJECT CLASS	EXPENDITURE CATEGORY	TOTAL AMOUNT OF THIS REQUEST
57	OBJECT CLASS	EXPENDITURE CATEGORY	TOTAL AMOUNT OF THIS REQUEST
58	111	Salaries
59	113	Benefits
60	220	Travel/Mileage
61	230	Contractual
62	233	Rental
63	240	Supplies
64	250	Equipment
65	290	Miscellaneous
66	361	Power
67	362	Water
68	363	Telephone
69	364	Trash
70	365	Insurance
71	450	Capital Outlay
72	TOTAL:		$ -
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74	OBJECT CLASS	APPROVED BUDGET	PRIOR PERIOD EXPENSES	CURRENT REQUEST	AVAILABLE BALANCE
75	OBJECT CLASS	APPROVED BUDGET	PRIOR PERIOD EXPENSES	CURRENT REQUEST	AVAILABLE BALANCE
76	111 - Salaries				$ -
77	113 - Benefits				$ -
78	220 - Travel/Mileage				$ -
79	230 - Contractual				$ -
80	233 - Rental				$ -
81	240 - Supplies				$ -
82	250 - Equipment				$ -
83	290 - Miscellaneous				$ -
84	361 - Power				$ -
85	362 - Water				$ -
86	363 - Telephone				$ -
87	364 - Trash				$ -
88	365 - Insurance				$ -
89	450 - Capital Outlay				$ -
90	TOTAL:	$ -	$ -	$ -	$ -
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