BOARD MEMBER COMPENSATION CLAIM FORM

This form is to be completed by a board member prior to receiving any per diem payment.

Date of Meeting
Name of Meeting
Amount Claimed
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     

Date_______________________________ Signature_______________________

Per diem rate:
$112.00/Regular Board Meeting
$62.00/Committee Meeting

Adopted: 12/4/00 BHD-2