AUTOMOTIVE REPAIR/ESSENTIAL MAINTENANCE REIMBURSEMENT
AUTHORIZATION
Student:
Student ID#
Date:
Vehicle Type/Make: ________________________ Vehicle License #: __________________________
To the Student:
I understand that this Auto Repair/Maintenance Voucher shall be used for the vehicle indicated above. I
also understand that misuse of this non-transferable form may result in my termination from the CARE
program.
In addition to signing this form, the student MUST PROVIDE THE FOLLOWING to the CARE program:
Verification Needed
Dates Turned In
Notes
Copy of the student’s current driver license
Unmet need: Date:
Copy of current vehicle registration
Access:
Original “proof of payment” and an itemized
receipt
is needed. Clearly, indicating how the car
repairs
were paid for, the receipt must indicate
form
of payment and show a zero balance.
Payment
must be itemized; an Internal audit,
review,
and verification of all documents will be
done, your
original proof of payment will be kept on
file in the business services department at MSJC
.
Colleague:
Approved: Yes N
o
If not approved; why?
Emailed Student status:
If all required documentation is received and Business Services approves the reimbursement, the process
normally takes 3-5 business weeks to process.
__________________________________________ _____________________________________ ________________
Student Signature Leslie Salas, Director Date
Vehicle repairs/maintenance must be made after the completion of the CARE Intake. Repairs/Maintenance must
include
ESSENTIAL PARTS/SERVICES for operation ONLY.
The
CARE program will reimburse up to $200.00 for auto repairs per semester. It is the student’s responsibility to
pay
for any amount that exceeds $200.00. Last day to submit a request is November 15, 2019. All receipts must be
submitted by
November 22, 2019, if it is not submitted, your request for reimbursement will be voided, and no
reimbursement
will be made.
Note: This document is valid only with an original signature from an authorized district representative.
Repair Date:
click to sign
signature
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