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Title II Part A - Private School Participation
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Request for Services of Title II A Funds SY 2020-21
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1Date Requested
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2School Name
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3Contact and Title
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4Phone Number
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5E-Mail
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Calculation of Expenditures
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aRegistration$0.00
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bBooks/Material$0.00
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cAirfare$0.00
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dHotel$0.00
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eTransportation$0.00
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fOther
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Total Amount Requested
(6a through 6f)		 $ - HIDOE APPROVED
(Yes or No)
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Note: All expenditures must be PRE-APPROVED. Expenditures may not be reimbursable if pre-approval is not received. For travel (air, hotel, taxi, shuttle, and rental car) there are strict policies and procedures that are required to be followed. If you book these on your own without prior approval, we will NOT be able to reimburse you.
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Total Amount Approved
 $ -
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Purpose and Use of Funds
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aExplain the purpose and use of funds requested. If funds are for workshops, include a brief summary of purpose, the names of teachers/ participants, identify title of class/course, name of provider, date, time, and location of class.)
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bHow does the expenditure meet the specific needs of the students at the school?
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cWhat grade level of students does this expenditure support?
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dHow does this expendiure relate to the Needs Assessment that was submitted by the school?
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eExplain how the activity is supplemental in nature; i.e., how would the school fund the activity absent Title II A funds?
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9Name of Vendor
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10Address of Vendor
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11Statement of Assurance
The applicant assures that the information provided above is correct.
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Signature
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Authorized Private School Official
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DEPARTMENT OF EDUCATION USE ONLY:
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Date Received by HIDOE:
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P.O. #ATP #
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OTM Form PS1
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