NEW JERSEY STATE DEPARTMENT OF EDUCATION Division of Finance
Office of Student Transportation

REQUEST FOR PAYMENT OF TRANSPORTATION AID - CHARTER AND RENAISSANCE SCHOOL STUDENTS

This request shall be filed by the parent or guardian of eligible charter and renaissance school students with the secretary of the local school district for the first and second semesters upon request. This request must be filed prior to the end of the fiscal year (N.J.A.C. 6A:27-3.4(b)).

I,
(Parent or Guardian)

do hereby certify that
(Name of Student)

who resides at		has been transported to (Address of Student - Street #, City/Town, State, and Zip Code)

situated in
(Charter/Renaissance School)	(City)	(State)

for the period of time from
Month	Day	Year

to
Month	Day	Year

In consideration thereof, I hereby request payment of transportation aid pursuant to N.J.S.A. 18A:39-1.

I do solemnly declare and certify under the penalties of the law that this request for payment is correct in all it's particulars, and that I am not claiming reimbursement or receiving transportation from any other school district for the same period of time.

(Date)	(Signature of Parent or Guardian)

(Daytime Telephone Number)

WHEN PROPERLY EXECUTED, THIS FORM MAY BE ACCEPTED AS AN OFFICIAL VOUCHER. THE LOCAL BOARD OF EDUCATION MAY PAY TRANSPORTATION AID BASED ON THIS CLAIM PURSUANT TO N.J.S.A. 18A:39-1 and 18A:19-3

C:\Users\Fpetrucci\Desktop\Request for Payment Transportation Aid -Charter School Version 9/2014