Strengthen Families Locally: Meeting Stipend & Reimbursement Request

Participation stipends and reimbursement for travel, child care, and supplies for Strengthen Families Locally meetings are available. Payments can be made by e-gift card, PayPal, or mailed check, depending on your preference. Please submit this form within 1 month of participating in a meeting. One form must be completed per meeting.

PLEASE NOTE: Per the IRS, any individual receiving $600 or more in payments during a calendar year (NOT including Child Care or Travel reimbursements) is required to report this income. In this case, you will be contacted by First 5 Fundamentals and asked to complete a Form W9, and you will receive a Form 1099-NEC for your annual tax return.

The Washington State Department of Children, Youth, and Families has contracted with First 5 Fundamentals to process stipend and reimbursement requests. All requests are submitted to DCYF to verify meeting participation before payment. Questions can be directed to cpachecojones@healthjusticerecoveryalliance.org

Name

First Name

Last Name

Phone

(###)

###

####

Meeting Information

Information about the meeting for which you are requesting a stipend and/or expense reimbursement

Meeting Date

YYYY

Meeting Location

Meeting Title or Topic

Are you requesting child care reimbursement?

Child care is reimbursed at $25 per hour for the total meeting time plus one hour of travel time, if applicable

Yes

Are you requesting reimbursement for travel costs?

Option 1

Option 2

What was your role in the meeting?

Participant (attended the meeting)

Contributor (presented or led a discussion during the meeting)

Organizer (planned meeting, purchased supplies and/or food)