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:
Copy of the student’s current driver license
Copy of current vehicle registration
Original “proof of payment” and an itemized
receipt
is needed. Clearly, indicating how the car
were paid for, the receipt must indicate
of payment and show a zero balance.
must be itemized; an Internal audit,
and verification of all documents will be
original proof of payment will be kept on
file in the business services department at MSJC
.
Colleague:
Approved: Yes N
o
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.
CARE program will reimburse up to $200.00 for auto repairs per semester. It is the student’s responsibility to
for any amount that exceeds $200.00. Last day to submit a request is November 15, 2019. All receipts must be
November 22, 2019, if it is not submitted, your request for reimbursement will be voided, and no
will be made.
Note: This document is valid only with an original signature from an authorized district representative.
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