Fiscal Return to the Oregon Department of Education

By completing this form, you are authorizing the Oregon Department of Education to issue an invoice to your institution to collect payment for the amount being returned. Warrant information should be available on the check or ACH documentation for the original payment, or you can log into EGMS and look under Web - Sub Grant in the Financial Details section. If you need additional assistance, you may email egms.refund@ode.oregon.gov.

Please only enter refund(s) for ONE subgrant per request. We will need to know how much to apply toward which claim(s).

Institution/Subrecipient/Vendor Name

What entity is sending back funding?

Contact Person First Name

Who should we contact with questions?

Contact Person Last Name

Contact Phone

Contact Email

Address Line 1

Address Line 2

City

State

Zip

Subgrant #

Subgrant number in EGMS (i.e. 5xxxx). Please only submit ONE subgrant number per request. If you are returning funds for multiple claims within that single subgrant, please specify in the Grantee Comment field how much each original claim was for, and how much of each claim you are returning.

Name of Grant

Which grant does this pertain to?

Warrant/Tracking #

(If known)

Warrant Date/Date Payment Was Received

(If known)

mm/dd/yyyy

Warrant Amount/Amount Paid

Amount of payment received via check or ACH

Amount Being Returned

How much of the original amount is being sent back?

Reason for Refund

Grantee Comment

Backup Documentation

Backup documents supporting this refund

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