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Enough Trainer Stipend Request
Enough Abuse Trainer Stipend & Travel Reimbursement
The South Dakota Department of Health, Rape Prevention Education (RPE) Program has provided funding for trainer stipend and travel reimbursement through May 2020. Prior to reimbursement, each trainer much have a W-9 form on file with the Center for the Prevention of Child Maltreatment at the University of South Dakota. To submit a W-9 form electronically, go to: https://na2.docusign.net/Member/PowerFormSigning.aspx?PowerFormId=9ff077b1-b629-42b9-9543-5767b4cd2084
Presenter Name
*
First Name
Last Name
Address for Payment Remittance
*
Street Address
City
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Delaware
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Tennessee
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Washington
West Virginia
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Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Email Address
*
Phone Number
*
Date of Training
*
Date Format: MM slash DD slash YYYY
Start Time
*
:
HH
MM
AM
PM
End Time
*
:
HH
MM
AM
PM
Host Organization
Training Location Address
*
Street Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Type of Training:
*
Strategies for Family and Community
Strategies for School and Community
Strategies for Youth Serving Organization
Understanding and Responding to the Sexual Behaviors of Children
She did WHAT? He Said WHAT?
It's Not Just Jenna Screening & Discussion
Number of Attendees
*
Please enter a number from
1
to
9000
.
Are you requesting reimbursement for travel expenses?
*
Yes
No
Travel from (home base)
*
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
Date you left home base
*
Date Format: MM slash DD slash YYYY
Time you left home base
*
:
HH
MM
AM
PM
Date you returned to home base
*
Date Format: MM slash DD slash YYYY
Time you returned to home base
*
:
HH
MM
AM
PM
Did you drive to this event?
*
A 'yes' response indicates that mileage reimbursement should be provided.
yes
no
License plate number
*
Type of vehicle
*
Personal vehicle
Agency or Organization owned vehicle
W-9 Form
*
Anyone receiving payment, including reimbursement, must have a current W-9 Form on file with the University of South Dakota.
To complete a W-9 form, copy and paste the web address into a new browser window: https://na2.docusign.net/Member/PowerFormSigning.aspx?PowerFormId=9ff077b1-b629-42b9-9543-5767b4cd2084
I have submitted a W-9 form.
Affirmation
*
By submitting this request for stipend, I affirm and agree to the following statements:
The information presented above is true and correct to the best of my knowledge.
I did not and will not receive payment or reimbursement from any other source, including my employer, to perform the training for which a stipend is requested.
I have reported the training and data from the training to Children’s Home Society.
I have submitted a W-9 form to USD (first request only)
Comments
Comments
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