Syllabus Adjudicator Reimbursement Form

For use both for in-person or online Syllabus adjudication.

Adjudication Date(s)(Required)

District(Required)

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone(Required)

Email(Required)

Was this adjudication in-person or online?(Required)

In person

Online

Adjudicator Hourly Rate(Required)

With Adjudicator Confirmation ($55/hr)

Without Adjudicator Confirmation ($49/hr)

Qualifying Minutes of Adjudication(Required)

Paid for minutes for each exam, conference, forfeit, and break. Exclude lunch.

Total Hourly Wages

Price: $0.00

Mailing Minutes(Required)

You will be paid for an additional 30 minutes per adjudication day to cover materials and postage for mailing evaluation forms and certificates to teachers.

Mailing Reimbursement

Price: $0.00

Distance from Home(Required)

How many miles (one way) was the adjudication site from your home?

Total Miles(Required)

(Mileage paid at standard IRS business reimbursement rate.)

Mileage Reimbursement

Price: $0.00

Adjudicator Meal Days(Required)

List the number of days where you adjudicated more than 60 miles from your home. Enter 0 if none.

Meal Reimbursement

Price: $0.00

($35/day for days when the adjudication site was more than 60 miles from adjudicator's home.)

Lodging Reimbursement

Will be paid, up to $225 per night/per room when:

1.The adjudication site is more than 60 miles from adjudicator’s home and includes a minimum of three hours of adjudication, or;

2.The assignment includes two or more consecutive days of adjudication with a minimum of three hours per day of adjudication.

Attach a copy of the hotel bill – credit card receipts/statements are not accepted.

Lodging Price(Required)

Enter price based on parameters listed above. Enter "0" if you have no reimbursable lodging expenses.

Schedule and Receipt Upload(Required)

Upload your Adjudicator schedule and, if applicable, a copy of your hotel bill. (Credit card receipts/statements are not accepted.)

Drop files here or

Max. file size: 16 MB.

Schedule Upload(Required)

Upload your Adjudicator schedule.

Drop files here or

Max. file size: 16 MB.

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Syllabus Adjudicator Reimbursement Form

Syllabus Adjudicator Reimbursement Form

Lodging Reimbursement

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