2017-2018 Program and Budget Handbook

ATTACHMENT H (revised 7/28/16)

Los Angeles Unified School District Federal and State Education Programs TITLE I IMPREST FUND CLAIM FORM

Section A

School Name:

Local District:

7S046 7E046


Claim No:

Vendor Account No. :

Vendor Name: Prepared by:



Section B

Check No

GL Account

Date Received



Fund Functional Area Cost Center No.

To access this form go to achieve.lausd.net/fsep , then click on Publications


I certify that 1) the above statement is correct and that all materials listed thereon have been received; 2) there is no profit of any kind for me in this claim and that is in accordance with Section 60071 of California Education Code; and 3) charges to donation are within the donor's stipulated allowable use.

Signature of Administrator

Print Name of Administrator


Title I Allowable GL Accounts (Commitment Items)

430010 Instr Material-General Purpose 520002 Travel/Conference Attendance

580005 Admission Fees 580012 Contract Bus Services

Special Instructions

Ensure all required supporting documents are attached to email, e.g. SPSA or SPSA Modification, itemized receipt/invoice for the purchase and/or approved 10.12.1 travel form or approved 34-EH-57 field trip form. Email completed claim form to fsep@lausd.net with following subject line on your email " Imprest - School/Office - Claim Number (current fiscal year- cost center-claim count-FG) ". FSEP will not accept faxes. The lack of adherence to these procedures may delay the timely processing of the Federal Grant (Title1) Imprest Fund Claim. Appendix D-3

Form no. IMP-1706FG


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