Form B.1 Il 569-00002 - Basic Reimbursement Form

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For Board Use Only
Illinois Law Enforcement Training and Standards Board
__________________________
6th St Road, Rm 173
Probationary Period ________
Springfield, Illino
03-6617 • Telephone 217/782-4540
__________________________________________________
Tuition ___________________
Food and Lodging __________
BASIC REIMBURSEMENT FORM
Transportation _____________
Total Correct ______________
Law Enforcement/Correctional
Approved _________________
Claimant (City, County, etc.) ______________________________________________________________________________
Name of Trainee _______________________________________________________________________________________
PTB ID
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.) For example: your
claim must be reduced by the same dollar amount of a grant received for the trainee’s salary while in basic training.
Tuition and Registration Fees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ (1) _______
Lodging (Receipts MUST be attached if not included as part of tuition or registration fee) . . . . . . . . . . . . . $ (2) _______
Food (Specify # of Breakfast ___ Lunch ___ Dinner ___) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ (3) _______
Salary for training period ($15.50 fixed rate times _____ hours in course) . . . . . . . . . . . . . . . . . . . . . . . . . . $ (4) _______
Transportation costs (Number of miles ______ @ 54 cents per mile)
. . . . . . . . . . . . . . . . . . . . . . . . . $ (5) _______
NOTICE: Mileage is a vehicle service allowance not an individual allowance for each officer.
Subtotal . . . . . . . . . . . . . $ (6) _______
Reimbursable Indirect Costs (50% of line 6) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ (7) _______
Reimbursable Direct Costs (sum of lines 1, 2, 3 & 5) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ (8) _______
MAXIMUM REIMBURSEMENT (the lesser of lines 7 or 8) . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . .$ (9) _______
Were any costs associated with the training (including salary) 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.
Form B.1 IL 569-00002 (07/09)
Submit Original

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