| Event Name: | Coordinator: | Phone: | |
| Email: | |||
| Event Start Date: | Address: | ||
| Address2: | Initials: | ||
| Statement: | My total compensation (including complimentary services received from Providers) for this trip is not more than the value of the trip. | ||
| INCOME | Total Signup fees: | ||
| Deposits to HSC Treasury | Total Party fees: | ||
| (use Record of Depost forms) | Amount | Comments/Source | |
| Total Income: | $0.00 | ||
| EXPENSES | |||
| (Paid directly by HSC) | Amount Paid | Payee/Purpose | Amt wo receipts |
| Subtotal: | $0.00 | $0.00 | |
| Account Balance | $0.00 | Equals Income less Expenses | |
| Closeout Items | |||
| Signup fees and other event expenses for which the coordinator has not been previously reimbursed | Amt Paid | Payee/Purpose | Amt wo receipts |
| Signup fees | |||
| Subtotal: | $0.00 | $0.00 | |
| Total Expenses: | $0.00 | Sum of Expenses Paid by HSC & by Coordinator | $0.00 |
| Requested Closeout Amt: | $0.00 | (expected to be <= account balance) | |
| Balance to HSC Treasury: | $0.00 | (must be >= 0, unless board approved subsidy) | |