EDUCATIONAL MATERIALS WORKSHEET
Date: Fall Spring Summer Year
Name of Student:
SBN: Case Number:
Did you receive an EOPS Book Voucher? Yes
No
Amount Received:
Required information in order for request to be process.
GAIN Services Worker's Name: File Number:
Phone Number: Fax Number:
Total of Books:
Total of supplies:
Subtotal:
Current Sales Tax Tax:
Total Miscellaneous:
EOPS Bookvoucher:
Total:
Approved by:
Pg 1 of 2
* GSW will have the final approval for reimbursement of books and supplies.
TO BE VERIFIED BY CalWORKs STAFF
Cost of Books
Name of Author
Cerritos College
CalWORKs Program
Name of Textbook
Course Name
$0.00
9.75%