Scholarship Holder Acquittal Form

Scholarship Holder First Name *

Scholarship Holder Last Name *

Email *

Mobile

Direct Deposit Details

Account Name *

BSB *

Account Number *

Items & Cost of Reimbursement/s

Please put what the item is, detail of item (if not obvious) and the total cost as per the tax invoice in Australian dollars, including GST.

Examples:

Item = Flights

Detail = 2022 World Cup to Spain

Total = $3000.15

__ ___ __

Item = Uber

Detail = Airport - Accommodation, 2022 Nationals

Total = $50.11

1. Item *

1. Detail of Item *

1. Total inc GST AU$ *

2. Item

2. Detail of Item

2. Total inc GST AU$

3. Item

3. Detail of Item

3. Total inc GST AU$

4. Item

4. Detail of Item

4. Total inc GST AU$

5. Item

5. Detail of Item

5. Total inc GST AU$

6. Item

6. Detail of Item

6. Total inc GST AU$

7. Item

7. Detail of Item

7. Total inc GST AU$

8. Item

8. Detail of Item

8. Total inc GST AU$

9. Item

9. Detail of Item

9. Total inc GST AU$

10. Item

10. Detail of Item

10. Total inc GST AU$

TOTAL to be reimbursed AU$ *

Tax Invoices

Please attach all associated tax invoices (in PDF or Word) that reflect the above itemised reimbursements. Please ensure they are tax invoices (will have an ABN on it and tax broken down).

If it is an international company, there will be no ABN.

1. Tax Invoice *

Browse

2. Tax Invoice

Browse

3. Tax Invoice

Browse

4. Tax Invoice

Browse

5. Tax Invoice

Browse

6. Tax Invoice

Browse

7. Tax Invoice

Browse

8. Tax Invoice

Browse

9. Tax Invoice

Browse

10. Tax Invoice

Browse

Declaration

In submitting this request for reimbursement, I agree that I am bound by the terms and conditions of the Sport Australia Hall of Fame Scholarship & Mentoring Program Scholarship Agreement.

I confirm that these expenses have not, nor will be, either reimbursed or paid by an additional third party.

I understand that the Sport Australia Hall of Fame (SAHOF) reserves the right to withdraw this grant if the conditions outlined in the Scholarship Agreement have been breached.

Scholarship Name *

Date *

Scholarship Signature *

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Office Use Only

Staff Name

Approved Date

Claim Amount

Approved Amount

Staff Signature

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