I, / of
[1](complete name as it appears on your social security card or SS-4)
[2]Mailing Street Address / City / State / Zip Code
agree to attend the following training given by the: / WV Department of Education
(organization name)
at [3] (training location)
[4] (brief description of training event - if WV certified teacher, please state in this section and complete certification below)
[5]Date(s) of training: / From: / To:
The stipend shall be $ / 0.00 / per[6] / 0 / not to exceed $ / 0.00
The stipend shall be $ / 0.00 / per[7] / 0 / not to exceed $ / 0.00
The stipend shall be $ / 0.00 / per[8] / 0 / not to exceed $ / 0.00
Authorized Travel Expense [9]: (check only one box) / [10]Total: $
Will not be reimbursed.
Will be reimbursed upon proper documentation in accordance with the travel
regulations of the Agency not to exceed $ / 0.00 / .
Please check the appropriate box below [11] (check only one box)
I am not currently a full-time employee of the State of West Virginia or a county board of education.
I am currently a full-time employee of the State of West Virginia. - Complete Certification 1
I am currently a full-time employee of / BOE - Complete Certification 2
(enter county name)
WV DEPARTMENT OF EDUCATION / VENDOR
Authorizing Signature[12] / Date[13] / Vendor’s Signature[14] / Date[15]
Printed Name[16] / Taxpayer Identification Number (SSN/FEIN) [17]
Originating Office Name / Office of Internal Operations
1 / CERTIFICATION: Full-time employees of the State of West Virginia must complete.
It is hereby certified that the stipend to be received under this contract will not interfere with or detract from the full-time duties of the employee.
The amount of annual compensation received by / (above named vendor) from the State
of West Virginia for full-time employment during the current fiscal year will be $ / The vendor serves as
with the title of
(position) / (title)
Signature of Vendor’s Supervisor/Agency Head / Title / Agency Name
2 / CERTIFICATION: Full-time employees of the WV Boards of Education must complete.
We certify that the time period covered under this contract is one of the below – check only one box: (Employee is REQUIRED to sign below)
That there is no compensation for the services covered by this contract (i.e. travel only)
That the services covered by this contract occur outside the hours in which this employee receives compensation; or
That both this employee and our organization are in compliance with Title 158, Series 14, regarding the filing of verified time records – (If you check this box, then supervisor MUST also sign)
(Signature of Employee) / (Signature of Employee’s Supervisor)
WVDE USE ONLY
Document ID #:[18] / Acct: / - / - / - / -
Vendor [19]#: / Program[20] / PPC[21] / Unit[22] / Fund[23] / Approp[24]
Check here if approval is required by the Attorney General. ¨ / Approved:
[1] Enter the individual’s name who will be attending/participating in a workshop, conference, meeting, etc. If person is providing a service, please use ED-48 Service Contract.
[2] Enter the remit to address where individual receives mail.
[3] Enter the training location.
[4] Enter a brief description of the event in which you are attending/participating.
[5] Enter the stipend dates here. The stipend provided under this contract HAS to fall within these referenced dates, including travel dates. If this specific stipend is required for a period of a year within a grant funding period, you can use one stipend contract for the full year. If this is the case, in the “not to exceed $0.00” section, enter ‘open end’ instead of the $ amount.
[6] Acceptable: per hour, per day, per speech, per training session, per unit completed, etc. Unacceptable: per invoice, per contract, per agreement.
[7] Acceptable: per hour, per day, per speech, per training session, per unit completed, etc. Unacceptable: per invoice, per contract, per agreement.
[8] Acceptable: per hour, per day, per speech, per training session, per unit completed, etc. Unacceptable: per invoice, per contract, per agreement.
[9] Enter an X in the appropriate box. If travel is to be reimbursed under this contract, please estimate the maximum amount to be paid.
[10]10 Enter the total from the above stipend line items. (<=$5000) signed by Office Director or Division Chief; (>$5000 through $10,000) initialed by Office Director and signed by Division Chief; (>$10,000 through $25,000) initialed by Office Director and Division Chief; then, signed by Chief of Staff; and (>$25,000) initialed by Office Director, Division Chief, and Chief of Staff; then, signed by State Superintendent..
[11] Enter an X in the appropriate box.
[12] (<=$5000) signed by Office Director or Division Chief; (>$5000 through $10,000) initialed by Office Director and signed by Division Chief; (>$10,000 through $25,000) initialed by Office Director and Division Chief; then, signed by Chief of Staff; and (>$25,000) initialed by Office Director, Division Chief, and Chief of Staff; then, signed by State Superintendent
[13] Enter date of signature.
[14] Signed by individual listed on this form; or, if agency, signed by a representative. If agency, be sure to list both agency and representative name in the top section as indicated.
[15] Enter date of signature.
[16] Type name of authorizing signature.
[17] THIS FIELD MUST BE COMPLETED. If individual, SSN; if agency, FEIN number.
[18] If ED-4 was completed, enter the assigned Document ID #. If no ED-4 was completed, then the Finance Office will complete.
[19] Originating office will insert vendor number.
[20] Enter Program. Example: 03CXR.0
[21] Enter PPC - fiscal year which services are rendered. Example F2015 or S2015
[22]Enter Unit: Example: 0025
[23]Enter Fund. Example: 0313
[24]Enter Approp. Example: 13000