CLAIM FOR REIMBURSEMENT CHECKLIST

(A completed form should be attached to each Claim for Reimbursement.)

ONLY THE 2009 CLAIM FORMS SHOULD BE USED. DO NOT USE OLD CLAIM FORMS.

THS-04 CLAIM

  • Project title and correct grant number/s are listed (Do not use Z numbers.)□
  • All cost category columns, including “Current Period Costs,” “Previous Costs,” □

“Total Costs,” and “Project Budget,”are complete

  • Project Director or designee has signed, dated, and listed e-mail, telephone and□ fax numbers (Signature should be signed in blue ink.)
  • The form has been printed in the portrait format and not the landscape format□
  • A copy of the GHSO approved Modification is attached, if applicable □

THS-02 PERSONNEL SERVICES

  • Agency name, grant number/s, and period for personnel services are listed□
  • Employee’s name, title, date paid, check or reference number, gross pay (1), □

fringe benefit rate (if applicable), fringe benefit amount (2), and total claimed

are filled out for EACH individual employee

  • Employee approved overtime/comp. sheets are attached and are in the same □

sequential order as listed on the THS-02

Check copies and overtime sheets are attached □

  • shows the hours worked
  • shows hourly base rate of pay
  • shows overtime rate of pay, if applicable
  • shows the number of overtime hours worked, including an explanation

for the overtime hours (i.e. radar, checkpoints, etc.)

  • Project Director or designee has signed, dated, and listed the e-mail and □

telephone numbers

THS-03 OTHER COSTS

The first three (3) columns on this form should be filled out for all cost categories:

  • Date invoices were paid□
  • Item – Payee’s Name and Description (i.e. Dell – 2 computers)□

If a grant employee’s name is listed for incurred costs, a brief explanation should

be shown in parentheses, i.e. David Walker (January cell phone)

  • Check/Reference number is completed□

ALL INVOICES/DOCUMENTATION SHOULD BE IN THE SAME SEQUENTIAL ORDER AS LISTED ON THE THS-03.

The form consists of five (5) different cost categories:

1)Non-Personnel (travel and supplies, etc.)

2)Capital Purchases

3)Professional Fees

4) Other Non-Personnel Costs

5) Indirect Costs

Non-Personnel - Travel Costs

Verify expenditure is allowable in present grant budget□

Copy of approved GHSO Travel Authorization– THS-09□

Verify per diem rate is correct for the designated traveled county □

Copy of theCONUS rate sheet is attached for out-of-state travel

()

Copy of the agency’s Travel Expense Report □

Itemize all incurred costs

Include a copy/s MapQuest (), or

other similar supporting document,for all miles traveled.

Agencies without a standardized report will request one from the

GHSO, - THS-05.)

Copy/s of itemized hotel bill showing a zero balance□

Copy/s of airfare ticket (e-ticket is acceptable)□

Copy/s of conference agenda along with literature indicating hotel rate□

Copy/s of attendance or sign-in sheet for training classes, if applicable□

Receipt copies for parking ($8.00 or more), and taxi□

Copy of the car rental contract, if applicable□

Copy/s of meal receipts (non-profit organizations only)□

Non-Personnel - Office Supplies, Communications, etc.

Verify expenditure is allowable in present grant budget□

Invoice copy/s□

Receipt copy/s, i.e. Wal-Mart, Office Depot, Staples, etc.□

Check copy/s OR Purchase Order/s□

Other Non-Personnel - This category includes subscription and membership renewals,

organizational permits, advertising, etc.

Verify expenditure is allowable in present grant budget□

Invoice copy/s□

Check copy/s OR Purchase Order/s□

Capital Purchase

Verify expenditure is allowable in present grant budget□

EACH equipment purchase costing $5,000.00 and over must be approved by□

GHSO and NHTSA prior to purchase

Invoice copy/s□

Check copy/s OR Purchase Order/s□

Copy/s of bids which are determined by the agency’s purchasing procedures. □

Agencies lacking standardized purchasing procedures must adhere to the

state’s purchasing guidelines.

THS-22 form□

For eachindividual item costing$1,000.00 or more

Agency’stagnumber/s and manufacturer’s serial number/s are complete

Professional Fees

Verify expenditure is allowable in grant budget□

Invoicecopy/s□

Check copy/s□

Third party contract, if applicable□

a) Signed invoice/s

b) Check copy/s

c) Travel expense report, if applicable

All Cost Category Totals Are Correct□

Project Director or designee has signed and dated the THS-04 (in blue ink), THS-03 and THS-02 □

A Personnel Certification Agreement is attached□

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REMINDERS:

1.EFFECTIVE AUGUST 1, 2011, THE STATE’S MILEAGE REIMBURSEMENT RATE INCREASED FROM.46 CENTSPER MILE TO .47 CENTS PER MILE UNTIL SUBSEQUENTLY MODIFIEDOR WITHDRAWN.

2. THE STATE’S LODGING RATES HAVE ALSO INCREASED UNTIL SUBSEQUENTLY MODIFIED OR WITHDRAWN.

3.ALL SUPPORTING DOCUMENTS MUST BE SINGLE SIDED AND 8½x11.

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Signature Date

Revised 10/08