On Site Cyber School Payment Request Month of ____________ 20___

Complete on a biweekly basis & submit to the Cyber School Administrator at least one week prior to the pay date for that period

Name of Teacher
	Employee #
	
Student Receiving
On Site Cyber School Instruction
	Grade Level
	
Name of Course(s)
	Budget Code

	Dates of Instruction
	# Hours of Instruction
	Rate
	Amount
	
1
					
2
					
3
					
4
					
5
					
Signature of Teacher

Date
	
Signature
Of Cyber School Administrator

Date
	
Tracy Harris, Director of Finance
	
Date

Please explain any discrepancy between hours of instruction and rate of pay: (i.e. “student did not show”)

Revised 01/14/2020