Attachment B - Request for Reimbursement Final.xlsx
XLSX spreadsheet 151 KB Posted
- Attached to
- DFSJW DFS-CISM-2024 RFR
- Solicitation number
- BD-23-1021-DFS-DFS01-89508
- Issued by
- Massachusetts
About this file
This document is an Attachment B - Request for Reimbursement form for the Department of Fire Services FY24 Critical Incident Stress Management Grant in the state of Massachusetts. The form requires the recipient to provide programmatic and financial details related to expenses incurred and reimbursements requested under the grant. Key details include the recipient's contact information, a description of the expenses being reimbursed and their associated benefits, as well as any success stories or sustainability measures implemented. The financial summary section requires detailed line item information such as quantity, unit cost, vendor name, delivery and payment dates. The form must be completed electronically and submitted to the Department of Fire Services.
The total reimbursement request amount, as well as any non-reimbursable amounts paid by the recipient, are calculated automatically based on the financial details provided. The authorized signatory must certify that the information is true, accurate, and that all equipment was purchased and paid for in accordance with the grant award terms and conditions. The contract opportunity associated with this reimbursement form is the DFSJW DFS-CISM-2024 RFR, which is a state-level contract opportunity in Massachusetts.
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Other files
| File | Type | Posted |
|---|---|---|
| consig~35.doc | DOC document | |
| newEFT-form~14.pdf | ||
| newmass-w9~11.pdf | ||
| CISM Funding RFR 2024 Final.pdf | ||
| Bidders Response Form CISM Final.docx | DOCX document | |
| Non Collusion Form~48.doc | DOC document | |
| Attachment A - Funding Application Form Final.xlsx | XLSX spreadsheet |
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Text version
Programmatic Summary
| Department of Fire Services |
| FY24 Critical Incident Stress Management Grant Reimbursement Request Form |
Programmatic Summary
Recipient Name: Team Director:
Award Amount: Email: 1. In the "Recipient Name" field, select your team name from the dropdown box.
Street Address: Asst. Team Director: 2. Complete all narrative fields in the form.
Municipality: Email: 3. Complete the Financial Summary page by clicking on the "Financial Summary" tab at the bottom of this page.
| Please describe the expenses for which reimbursement is being requested and the associated benefit to the recipient: | |
| HANDWRITTEN SUBMISSIONS WILL NOT BE ACCEPTED |
Please cite any specific success stories that occurred as a result of these funds:
Please describe any measures being implemented to support the long-term sustainability of the investments made with this funding:
| Department of Fire Services • P.O. Box 1025, State Road, Stow, MA 01775 | 1 | Page |
| 978-567-3100 • www.mass.gov/dfs |
http://www.mass.gov/dfs Financial Summary
| Department of Fire Services |
| FY23 Critical Incident Stress Management Reimbursement Request Form |
| Financial Summary | ||||||||||||||
| Item Description | Quantity | Unit Cost | Shipping Cost | Total Cost | Vendor Name | Date of Delivery | Date of Payment | Quantity | Unit Cost | Vendor Name | Delivery | Date of Payment | ||
| 5 | 5 | 5 | 5 | 5 | 1. Fill out all columns for each eligible item purchased using this grant funding. Reports with red highlighted omissions will not be accepted. The total cost of each line item will not be added into the total at the bottom of the spreadsheet until all required information has been inputted. |
2. If able to sign electronically, insert signature in "Authorized Signatory Name" field.
3. Submit document to OPS.DFS-TM-Grants@mass.gov. If unable to sign electronically, print and sign a copy, then email to OPS.DFS-TM-Grants@mass.gov.
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| Total Expenses: | $0.00 | |||||
| Non-Reimburseable Amount Paid by Recipient: | $0.00 | |||||
| Total Reimbursement Request: | $0.00 |
All line items in this report must be accompanied by an invoice and proof of payment (cancelled check copy or other official financial system record) to be eligible for reimbursement.
I certify under the pains and penalty of perjury under Massachusetts law that: i) I am qualified and authorized to execute this document as the Team Director ii) the foregoing information is true and accurate iii) that all equipment was purchased and paid for in accordance with the terms and conditions of the FY24 CISM Grant Award, iv) that all equipment was delivered to and paid for by the grant recipient on the dates so indicated.
Authorized Signatory Title Authorized Signatory Name Signature Date
Contact Info
| Organization | Primary Point of Contact | Email Address | Phone Number | Street Address | PO Box | Municipality | State | Zip Code | Secondary Point of Contact | Email Address | Phone Number | Street Address | PO Box | Municipality | State | Zip Code | Award Amount | ||||
| Title | First Name | Last Name | Title | First Name | Last Name |
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