Fillable Financial Form

Annual Financial Status Report

Calendar Year

Chapter Name

ALL FUNDS ON HAND as of 31 December

REQUESTED IMBURSEMENT TO CHAPTER ACCOUNT

1) Operating and administrative expenses provision =  $500 + $5 per attendee (attach signed attendance lists)
Basic Provision 
$______$500_______
Total Attendance for the year:
_________________ attendees
# of attendees * $5 = 
$_________________
TOTAL attendance amount 
$_________________

2) Reimbursements
a) Meeting expenses: (not including alcoholic beverages and/or branded merchandise)   $_________________
 (attach receipts for all meeting expenses)

b) Expenses for Speakers: [80% reimbursement to $500 max]
  i) Honoraria: 
$_________________
  ii) Travel Expenses: 
$_________________
Total Speaker Expenses 
$_________________
Total Speaker Expenses * 0.8 
$_________________
TOTAL Reimbursement [not to exceed $500] 
$_________________

c) College Participation: [reimbursement to $500 max]
   i) Awards/Activities/Scholarships: (not including payment of ASA dues)
$_________________

ii) Student Travel Expenses: (not including travel to national meetings)
$_________________

Total College Participation Expenses 
$_________________
TOTAL Reimbursement [not to exceed $500] $_________________

d) High School Awards Presented: $_________________
TOTAL High School Awards Reimbursement [not to exceed $200] 
$_________________

e) Talks at Local Schools: 
$_________________
TOTAL Talks at Local Schools Reimbursement [not to exceed $500] 
$_________________
TOTAL IMBURSEMENT 
$_________________
If the total imbursement plus the remaining funds in the chapter bank account is over $2000, then subtract
that amount over $2000 from the requested imbursement to arrive at the requested amount.

TOTAL REQUESTED IMBURSEMENT $_________________

Treasurer:_________________________President:________________________Date:____________;

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