Form B.2 Il 569-00010 - Non-Basic Reimbursement Form
Download a blank fillable Form B.2 Il 569-00010 - Non-Basic Reimbursement Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form B.2 Il 569-00010 - Non-Basic Reimbursement Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2Illinois Law Enforcement Training and Standards Board
For Board Use Only
______________________
Probationary Period ____
Springfield, Illinois
6
• Telephone 217/782-4540
Tuition _______________
Food and Lodging ______
__________________________________________________
Transportation _________
Total Correct __________
Approved _____________
NON-BASIC REIMBURSEMENT FORM
Claimant (City, County, etc.) ______________________________________________________________________________
Name of Trainee _______________________________________________________________________________________
PTB ID Number
Last
First
Middle
Date Appointed as Officer ________________ Date of Birth __________________ Rank _____________________________
Type of Training (Specify): _____________________________________________________________________________
Date Training Commenced ____________________ Date Graduated ____________________ Hours in Course ____________
Date training terminated if not graduated and reason for termination: ______________________________________________
______________________________________________________________________________________________________
Name and Location of School _____________________________________________________________________________
TOTAL ACTUAL COST OF TRAINING: (Costs covered by funds from any other source may not be claimed.)
Tuition and Registration Fees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ _______
Lodging (Receipts MUST be attached if not included as part of tuition or registration fee) . . . . . . . . . . . . . . . . $ _______
Food (Specify # of Breakfast ___ Lunch ___ Dinner ___) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ _______
Transportation costs (Number of miles ______ @ 54 cents per mile)
$ _______
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
NOTICE: Mileage is a vehicle service allowance not an individual allowance for each officer.
Total . . . . . . . . . . . . . . $ _______
AMOUNT CLAIMED FROM STATE OF ILLINOIS (50% of above total) . . . . . . . . . . . . . . . . . . . . . . . . .$ _______
Were any costs associated with the training paid for by a federal or state grant, or any funds from another agency or source?
YES ( )
NO ( )
If “yes”, please reduce your claim amount and explain in detail on a separate attachment.
Claim Preparer __________________________________________________ Telephone _____________________________
I certify the above facts and figures are true and correct.
___________________________________________________________________________________________________________
(Ink signature of Chief of Police or Sheriff) DO NOT Rubber Stamp
Date
I hereby certify that I am a duly-qualified and authorized official of the above named claimant and am responsible for the examination
and settlement of accounts; that the above amounts claimed for the State of Illinois are proper charges under the provisions of the Police
Training Act and payment has not been received.
___________________________________________________________________________________________________________
(Ink signature of Auditor, Comptroller, Clerk, or other fiscal officer. Indicate Title) DO NOT Rubber Stamp
Date
IMPORTANT NOTICE: The Board is requesting specific information that is necessary to accomplish the statutory purposes as outlined
in the Illinois Police Training Act and/or Public Act 7970-652. Failure to provide this information may prevent this form from being
processed. This form has been approved by the Forms Management Center.
Submit Original
Form B.2 IL 569-00010 (7/09)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal