LEA Payments to ODE Form



Oregon Department of Education Improvement255 Capitol Street NEODE Office NameSalem, OR 97310Local Education Agency (LEA) Refund Paymentto the Oregon Department of Education (ODE) FormSchool District: ________________________________________________________________NameInstitution ID # (4 digits)Reason for return of funds: FORMCHECKBOX Monitoring/Desk Audit Fiscal findingODE Monitoring Lead: _____________________________________________________Date of Visit/Audit: ________________________________________________________ FORMCHECKBOX Subgrant in aid over payment FORMCHECKBOX Other (explain)______________________________________________________________Superintendent/Agency Head:(Please print name)Authorized Signature:Make check payable to the Oregon Department of Education and attach form to payment.(Please list each subgrant that funds are being returned from as a separate line. The check may be the total of all funds returned.)Subgrant ID#AmountComments#$#$#$#$#$#$#$#$#$#$#$#$Total Amount Returned$Form available on web at: ode/schools-and-districts/grants/ESEA/Pages/ESEA-Monitoring.aspxODE Use onlySpecial Instructions:Return to subgrantReallocationReturn to USDEOther: ................
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