HEALTH & SOCIAL SERVICE SCHOOL EXPENSE FORM
I am requesting reimbursement or a vendor layaway payment for my child for expenses that I personally purchased or placed on
layaway for the current fiscal year for clothing as itemized below. I have attached all original supporting documentation of these
expenses in good faith and to the best of my knowledge are eligible for payment.
STORE NAME DATE PURCHASED CLOTHING ITEM COST
TOTAL REQUESTED $ ______________
Child’s Name ____________________________________________ID #________________ DOB ________________ Grade _______
Proof of school enrollment must be provided every school year. Receipts must be for clothing on your school age (K-12) child only, with
no groceries, cleaning supplies, etc. Please complete and attach along with your receipts the Health & Social Service Benefit/Direct to
Vendor Claim Form. List the articles of clothing you are claiming rather than copy what appears on the receipt.
Parent/Guardian Signature _________________________________________________ Date _______________________