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GLENDALE COMMUNITY COLLEGE CalWORKs Program | Unnamed: 1 | Unnamed: 2 | Unnamed: 3 | Unnamed: 4 | Unnamed: 5 | Unnamed: 6 | Unnamed: 7 | Unnamed: 8 | Unnamed: 9 | Unnamed: 10
ANCILLARY REQUEST |  |  |  |  |  |  |  |  |  | Instructions
 |  |  |  |  |  |  |  |  |  | FIRST - Go to MY GCC and print your book list.
1. Request for: |  | Reimbursement |  | Advancement |  | Date: | 2013-02-12 00:00:00 |  |  | 1.  If you have already paid for your books, supplies, and fees, check "Reimbursement."  If you have not yet paid, check "Advancement."
2. Name of Student: |  |  |  |  |  |  |  |  |  | 2. Your name
3. DPSS Case # |  |  |  |  |  |  |  |  |  | 3.  Your DPSS Case Number
THE ITEMS LISTED BELOW ARE NEEDED FOR THE STUDENT'S PARTICIPATION IN CLASS
 | 4. SEMESTER: |  |  |  |  |  |  |  |  | 4.  The semester for which you are requesting books & supplies
 |  | 5. BOOKS: |  |  |  | 6. COST BEFORE TAX:
 |  |  |  |  |  |  |  |  |  | 5. Enter the books you purchased which were required for your class.
 |  |  |  |  |  |  |  |  |  | 6.  Enter the cost of each book (not including tax).
 |  |  |  | SUB-TOTAL: |  | 0
 |  |  |  | TAX: (9.00%) |  | 0
7. EOPS Voucher |  |  |  |  |  |  |  |  |  | 7.  Did you use an EOPS Voucher for this purchase?  If so, how much was the voucher?
 |  |  |  | TOTAL: |  | 0
 |  | 8. SUPPLIES: |  |  |  | 9. COST BEFORE TAX: |  |  |  | 8. Enter the supplies you purchased for your classes.  (Write a clear description of each item purchased.)
 |  |  |  |  |  |  |  |  |  | 9.  Enter the cost of each supply (not including tax).
 |  |  |  |  |  |  |  |  |  | à à à à à à à à à à à à
 |  |  |  | SUB-TOTAL: |  | 0
 |  |  |  | TAX: (9.00%) |  | 0
 |  |  |  | TOTAL: |  | 0
 |  | FEES AND OTHER ITEMS: |  |  |  | Not Taxable
 |  | 10.  Student Services Fee / ASB |  |  |  |  |  |  |  | 10.   If you bought parking, enter the cost here.
 |  | 11. Health Fee |  |  |  |  |  |  |  | 11. If you paid a Student Health Fee, enter the cost here.
 |  | 12. ID Card |  |  |  |  |  |  |  | 12.  If you paid for a Student ID, enter the cost here.
 |  | 13.  Parking |  |  |  |  |  |  |  | 13.   If you paid the Student Services fee, enter the cost here.
 |  | 14.  IMAT/LAB Fee |  |  |  |  |  |  |  | 14.  If you paid a IMAT/LAB Fee, enter the cost here.
 |  | 15. |  |  |  |  |  |  |  | 15.-17. If you bought untaxed textbooks online, enter the cost here.  Include shipping and handling fees.
 |  | 16.
 |  | 17.
 |  |  |  | SUB-TOTAL: |  | 0
 |  |  |  | TAX: (None) |  | 0
 |  |  |  | TOTAL: |  | 0
 |  | GRAND TOTAL: |  |  |  | 0
 |  |  |  |  |  |  |  |  |  | è  Print this form
 | Student Signature |  |  |  |  | Date |  |  |  | è Sign and date in the blue section.
 |  |  |  |  |  |  |  |  |  | è Staple your original receipts and Book List to this form and bring everything to the GCC CalWORKs front counter.
GAIN and REP Workers: Original Case Manager Signature, Stamp, and Seal are required for this form to be valid.
 |  |  |  |  |  |  |  |  |  | Check your work before you print!  Make sure that the amounts on this form match the numbers on your receipt.
 | Case Manager Signature |  |  |  |  | Date
GCC CalWORKs Stamp: |  |  |  |  |  | GCC Seal: