Lead in Schools—Reimbursement Program

Welcome

Please read the reimbursement guidance document on the DEQ website prior to completing this form.

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* 1. School Name

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* 2. School ID Number (ie MTOPIXXXX)

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* 3. Contact Person

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* 4. Contact Person Phone #

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* 5. Contact Person Email

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* 6. Mailing Address

Street address

Street address line 2

City

State

Zip code

Country

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* 7. Description of Lead Mitigation Performed

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* 8. Reimbursement Amount Requested $$ (maximum of $50,000/school)

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* 9. Amount of ESSER Funding Received

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* 10. Amount of ESSER Funds Spent to Date

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* 11. Amount of ESSER Funds Remaining that are not Obligated. (Obligated is defined as funding not currently spent but committed to a future task/activity/program)

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* 12. Intended Use of Obligated ESSER Funds. ( If school has unspent ESSER funds, the school must demonstrate how those funds have been obligated to be eligible for reimbursement)

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* 13. Upload Invoices, Receipts, and/or Supporting Documents (16 mb max) (Non-anonymous question)

Only PDF, DOC, DOCX, PNG, JPG, JPEG, GIF files are supported.

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

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* 14. I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information; including the possibility of fine and imprisonment for knowing violations. [75-5-633, MCA]

Select this box in order to certify