Neb. Admin. Code EDUCATION, DEPARTMENT OF, tit. 92, ch. 4, app C
NDE # 22-003
Revised effective (date to be inserted later)
DATE DUE: 2/15
TO: Nebraska Department of Education
The undersigned hereby makes application, pursuant to Neb. Rev. Stat. 79-734(2) and Title 92, Nebraska Administrative Code (NAC), Chapter 4, for distribution of funds appropriated by the Legislature for the purchase and loan of textbooks to private school children.
1. Total Number of Applications for Loan of Textbooks (Appendix A) Received 1. __________________
2. Total Number of Textbooks Requested 2. __________________
3. Total Number of Textbooks to be Purchased 3. __________________
4. Cost of Textbooks to be Purchased 4. $__________________
5. Shipping/Handling Charges Added by Seller/vendor, if Applicable 5. $__________________
6. Total Cost of Textbooks (Line 4 plus Line 5) 6. $__________________
7. Administration Expense (not to exceed 5% of amount listed on Line 6) 7. $__________________
8. Total Amount of Request (Line 6 plus Line 7) 8. $__________________
9. Amount of Carryover Funds Remaining From the Previous Year if the Total Amount Was Not Expended, if Applicable (Attach Explanation) 9. $__________________
10. Amount of Funds on Hand from any Sale of Unused Textbooks per Section 004,01F, if Applicable 10. $_________________
11. Amount of Funds on Hand from Reimbursements Received for Damaged Textbooks per Section 004.08, if Applicable 11. $_________________
12. Total Amount of Funds on Hand (Total of Line 9, Line 10, and Line 11) 12. $_________________
13. Adjusted Total Request (Line 8 minus Line 12) 13. $_________________
Attached to this application is a listing of the titles of each textbook requested (including the publisher and the International Standard Book Number (ISBN), if applicable), the number of copies of each textbook requested, the price per textbook, and if applicable, the amount of shipping and handling.
______________ ____________________________________
DATE SCHOOL DISTRICT NAME
________________________________
PRINT NAME OF SUPERINTENDENT OR DESIGNEE
________________________________
SIGNATURE OF SUPERINTENDENT OR DESIGNEE
(This application must be received by the Department of Education no later than February 15.)
Neb. Admin. Code EDUCATION, DEPARTMENT OF, tit. 92, ch. 4, app C