Receipt for Services Receipt for Services

Faculty Coordinator: ____________________________________ Faculty Coordinator: ____________________________________

Location: _____________________________________________ Location: _____________________________________________

Date: ________________________________________________ Date: ________________________________________________

Amount/currency of payment: _____________________________ Amount/currency of payment: _____________________________

Paid to: _______________________________________________ Paid to: _______________________________________________

For the following services: ________________________________ For the following services: ________________________________

______________________________________________________ ______________________________________________________

______________________________________________________ ______________________________________________________

______________________________________________________ ______________________________________________________

REQUIRED SIGNATURES REQUIRED SIGNATURES

Signature of recipient: Signature of recipient:

______________________________________________________ ______________________________________________________

Under penalty of perjury, I certify that for the purposes of Under penalty of perjury, I certify that for the purposes of
reimbursement, the items and totals listed herein are proper reimbursement, the items and totals listed herein are proper
charges for services rendered. charges for services rendered.

Signature of Faculty Coordinator: Signature of Faculty Coordinator:

__________________________________________________________ __________________________________________________________