Third party reimbursement Thanks for reaching out! Please complete the information below. Entity information Entity name Are you a nonprofit, local government, or public safety entity Nonprofit Local government entity Public safety Are you a 501(c)(3)? You may be required to provide an IRS determination letter Yes No Contact information Contact person first name Contact person last name Email address Phone number Request information What third party provider and service are you planning to utilize? (please review eligibility information) Anticipated reimbursement request amount (maximum of $20,000 per fiscal year) How does this service support your entity’s operations or programs? What geographic areas does your organization serve within Sourcewell's region? Please check all that apply Cass County Crow Wing County Morrison County Todd County Wadena County Public purpose Describe how the project primarily benefits your community within Region 5. Projects cannot primarily benefit any individuals, businesses, or nonprofit entities. The proposed project must relate to Sourcewell's government purpose as defined in Minn. Stat. 123A.21, Subdivision 7. Please identity all program or service areas to which the proposed project will relate. Programs or service areas the proposed project will relate? Administrative services Curriculum development Data processing Distance learning and other telecommunication services Evaluation and research Staff development Media and technology centers Publication and dissemination of materials Pupil personnel services Planning Secondary, postsecondary, community, adult, and adult vocational education Teaching and learning services, including services for students with special talents and special needs Employee personnel services Vocational rehabilitation Health, diagnostic, and child development services and centers Leadership or direction in early childhood and family education Community serices Shared time programs Fiscal services and risk management programs, including heath insurance programs providing reinsurance or stop loss coverage Technology planning, training, and support services Health and safety services Student academic challenges Cooperative purchasing service How does the proposed project promote and align with Sourcewell’s statutory purpose of providing programs and services as identified by your checkbox selections. This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
