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)
$500 $______500________
Total Attendance for the year:_______ attendees
# of attendees * $5 = $_________________
TOTAL provision $_________________

2) Reimbursements
a) Meeting expenses: (not including alcoholic beverages) $_________________
 (attach receipts for all meeting expenses)
b) Expenses for Speakers: [80% reimbursement to $500 max]
  i) Honoraria: $____________
  ii) Travel Expenses: $____________
Total Expenses $___________
Total 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 Expenses $___________
TOTAL Reimbursement [not to exceed $500] $_________________
d) High School Awards Presented: $_________________
TOTAL Reimbursement [not to exceed $200] $_________________
e) Talks at Local Schools: $_________________
TOTAL 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:____________;