PAY FORM
Home Team: ______vs. Visiting Team:______
Tournament - List Games ______
School District & Campus:______Date:______
Name:______/ SS#: ______
Address: ______/ City: ______/ Zip: ______
Write: Number of Games; Circle Girls or Boys Select One: Mileage or Rider’s Fee
______JHS Girls/Boys / Circle One Below / Enter roundtrip mileage if mileage selected
______9th Girls/Boys / 2 Officials / (1 car) 55.5 cents/mile x ____ miles = ____
______JV Girls/Boys / 3 Officials / (2 cars) 27.75 cents/mile x ____ miles = ____
______Varsity Girls/Boys / Rider’s Fee = $10 (Circle $10 if selected)
OFFICE USE ONLY / Signature of senior official will verify all information is correct.
Total Game Fees: / $______/ Official’s Signature: ______
Mileage/Rider’s Fee / $______/ Senior Official’s Signature: ______
Total Due: / $______/ District Authorizing Signature: ______
Name:______/ SS#: ______
Address: ______/ City: ______/ Zip: ______
Write: Number of Games; Circle Girls or Boys Select One: Mileage or Rider’s Fee
______JHS Girls/Boys / Circle One Below / Enter roundtrip mileage if mileage selected
______9th Girls/Boys / 2 Officials / (1 car) 55.5 cents/mile x _____miles = _____
______JV Girls/Boys / 3 Official / (2 cars) 27.75 cents/mile x _____ miles = _____
______Varsity Girls/Boys / Rider’s Fee = $10 (Circle $10 if selected)
OFFICE USE ONLY / Signature of senior official will verify all information is correct.
Total Game Fees: / $______/ Official’s Signature: ______
Mileage/Rider’s Fee: / $______/ Senior Official’s Signature: ______
Total Due: / $______/ District Authorizing Signature: ______
Name:______/ SS#: ______
Address: ______/ City: ______/ Zip: ______
Write: Number of Games; Circle Girls or Boys Select One: Mileage or Rider’s Fee
______JHS Girls/Boys / Circle One Below / Enter roundtrip mileage if mileage selected
______9th Girls/Boys / 2 Officials / (1 car) 55.5 cents/mile x _____ miles = _____
______JV Girls/Boys / 3 Officials / (2 cars) 27.75 cents/mile x _____ miles = _____
______Varsity Girls/Boys / Rider’s Fee = $10 (Circle $10 if selected)
OFFICE USE ONLY / Signature of senior official will verify all information is correct.
Total Game Fees: / $______/ Official’s Signature: ______
Mileage/Rider’s Fee: / $______/ Senior Official’s Signature: ______
Total Due: / $______/ District Authorizing Signature: ______
FEES quoted from SECTION 1204 of the UIL C&CR. See http://uil.utexas.edu/athletics/pdf/officials_payscale.pdf
ATTENTION SCHOOL OFFICIALS:For questions regarding payment, contact Carl Contrata at (956)-373-0751.