REQUEST
REIMBURSEMENT
Los Angeles Southwest College
CalWORKs/GAIN Program
BOOKS & SUPPLIES REQUEST/REIMBURSEMENT FORM
Page ____ of ____
Date: ____________Semester: _________________________ Student ID#: ______________________
Student’s Name ____________________________________ GAIN Case #: ____________________________
Phone Number: ____________________________________GSW’s Name: ___________________________
COURSE NAME
NAME OF BOOKS/SUPPLIES
BOOK PRICE
($)
SUPPLIES
PRICE ($)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Subtotal
$
$
Tax
$
$
Total
$
$
Fees (if applicable):
$
TOTAL GAIN REIMBURSEMENT/REQUEST AMOUNT
$
_____________________
________________________________________________________________
CalWORKs/GAIN Staff Authorization
By signi
ng below, I acknowledge that I have read the guidelines on the back of this form and I agree to follow them. I understand I must submit this original request and original receipts to my GAIN
Services Worker (GSW). I also understand that it is my responsibility to disclose whether I am receiving a book grant from EOPS or any other program. I must also consult with the LASC CalWORKs staff
before adding, changing, or dropping classes.
Student’
s Signature Date
*PLEASE TURN OVER FOR MORE INFORMATION*
Revised 3.17.2020
Health Fee
Fees (if applicable):
Parking Permit
o ASO Fee
Rep. Fee
INSTRUCTIONS
Please:
CalWORKs Stamp
________________________________________
CalWORKs/GAIN Staff Authorization
Total all fees here:
Complete and be specific
Type each item without tax
Type 0.095 in the Tax box
$
0.00
$11 Summer
0.00
$7 Summer
0.00
$3 Summer
Print Form
Reset Form
$2 Spring
click to sign
signature
click to edit
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signature
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PLEASE CAREFULLY READ THE FOLLOWING INFORMATION REGARDING YOUR
BOOK AND SUPPLY REQUEST/REIMBURSEMENT FORM:
In order to have this form processed, you must be an active participant with the Los Angeles Southwest College CalWORKs/GAIN
Program and in good standing with the program, the college, and the county GAIN and CalWORKs Programs.
Your GAIN worker may ask you to sign a form called a WtW 8. This form says that you will use your financial aid for books and
supplies. You are not required to use your financial aid for your books and supplies. If you do not want to use your financial aid,
check “no” on the form. If you have signed the form and agreed to use your financial aid, you can change your mind at any time
and decide that you want GAIN to pay. You must notify your worker that you have changed your mind.
You are not required to use your own money to pay for your books and supplies after you have been certified in this office. It’s to
your advantage to submit your request as early as possible, so that you have your books on the first day of classes.
If you have previously purchased your books you will be entitled to a reimbursement. In order to request a reimbursement, you
must complete a Book & Supplies Request form for those items separately and submit ORIGINAL receipts along with the request.
No exceptions
.
When completing your book request, make certain you provide the book, supplies and other fees information in the correct
columns. Do not total the columns, as CalWORKs staff will do so when you submit the form.
You will not receive the requested funds unless the Book & Supplies Request form is processed and signed by the LASC CalWORKs
Office staff and received and approved by your GSW. Do not submit your book forms to your GAIN worker directly; all forms must
be processed by our office first.
If you ask GAIN to pay for your books and supplies for which another program already paid, it is called “double-dipping” and is
considered FRAUD. We are required to report fraud to the college, the state, the county Department of Public Social Services
and law enforcement. Serious consequences may result.
Once you have purchased your books and supplies, bring your ORIGINAL RECEIPTS to the CalWORKs Office so that copies can be
made and placed in your file. PLEASE NOTE: You MUST submit your ORIGINAL RECEIPTS to your GSW via mail or in person (in
person strongly recommended). Failure to do so may prevent you from receiving these benefits the following semester or may
result in an overpayment by your GSW. Also,
the LASC Bookstore DOES NOT ISSUE DUPLICATE RECEIPTS UNDER ANY
CIRCUMSTANCE; therefore, please safeguard your receipts.
Please ask if you have any questions whether a book or supply is allowable before you purchase it. GAIN will not pay for any items
unrelated to your welfare-to-work plan. Please provide a copy of your course syllabus if you are requesting any unusual or costly
items (i.e. scientific or graphic calculators, art supplies, gym clothes, lab items, tape recorders, flash drives, etc.). Please note that
most GSWs will only pay for one book bag/backpack & dictionary reference set per year.
Please note that your request will not be signed should you choose to enroll in a non-authorized general education course or
major program.
We cannot submit and requests for books or supplies for classes in which you are not enrolled. Standby status is not enrollment.
If you are permitted to enroll after a class begins, please submit your add card to Admissions and obtain a new registration receipt.
Please note that we cannot submit requests for any books or supplies you need for enrollment at another college or for courses
which do not support your welfare-to-work plan.
Your GSW will not pay for textbooks previously approved and funded.
Have a highly productive semester!