Free 41184.pdf - Indiana

Reset a Form REQUEST FOR APPROVAL OF EXPENDITURE
State Form 41184 (R3/4-05) Approved by State Board of Accounts, 2005

Indiana Protection and Advocacy Services

INSTRUCTIONS: 1. Complete before any expenditure (i.e. purchase of equipment or supplies,
training request, services or request for reimbursement) 2. All supervisors in chain of command must approve before request reaches Fiscal 3. If approved by Fiscal, request goes on to Executive Director for consideration.

Name:

Date:

Cost Estimate:
(For Training, remember to attach the Cost Estimate Worksheet and include all known estimated costs, including salary, hotel, travel, registration etc.)

Request approval for the following expenditure: Purchase is needed for these reasons: MUST BE INITIALED IF EXPENDITURE IS REQUESTED FOR TRAINING OR CONFERENCE:
I am aware of the cancellation and refund policy of the event. If I do not attend after being approved and registered, I acknowledge that it is my responsibility to cancel all arrangements, registration, lodging, flight etc. and to obtain refunds. I acknowledge that I am responsible for any costs incurred by the agency as a result of my failure to attend any approved training or conference, and may be required to reimburse the agency.

Initials:

List Program(s) and Goal(s):

SUPERVISORY USE ONLY
Note that the Supervisor is to consider this request only in terms of is/was it needed to further the agency's mission or priorities.

Primary Supervisor Signature: Intermediate Supervisor Signature: Supervisory Comments:

Approved: [ ] Denied: Denied: [ ] Approved: [ ] [ ]

Date of action: Date of action:

FISCAL USE ONLY
Note that Fiscal is to consider this request only in terms of is/was it an allowable cost per program requirements, and are there sufficient funds.

Fiscal Office Signature: Fiscal Office Comments:

Approved: [ ] Denied: [ ]

Date of action:

EXECUTIVE DIRECTOR USE ONLY
Executive Director Signature: Executive Director Comments: Approved: [ ] Denied: [ ] Date of action:

If denied, the original will be forwarded to the Administrative Secretary for distribution. Upon full approval, forward the original to the Administrative Secretary for distribution. DISTRIBUTION: ORIGINAL TO FISCAL. Copies to 1) Requestor, 2) Immediate Supervisor, 3) Intermediate Supervisor (if any), and 4) if a Training Request, copy to Education and Training Director.

Date returned to requesting staff by Administrative Secretary: