Fee Based Programming Report

Please submit this form upon completion of an event subject to Partial Cost Recovery.

Date*
MM slash DD slash YYYY

Select the date that you are submitting your forms and check to Cash Management.
Event Name*

Please type the name of the event exactly as you reported it to Cash Management on AG-231.
Contact Name - Lead Agent*

Please type the name of the lead agent sending in the deposit.
County*

Please indicate what County you are in.
Event Date*
MM slash DD slash YYYY

Please select the first day of the event. If the event is more than one day, please list the additional dates in the next section.
Additional Dates

Please type in the date of the event (MM/DD/YY). If the event had multiple days use a dash or separate the dates with commas. Example 1: 05/06/11 - 05/07/11 Example 2: 05/06/11, 05/13/11, 05/20/11 If there are no additional days type NONE or leave it blank.
Registration Fee*
Please type the amount charged to each registrant. DO NOT type the $ sign.
Number of Registrants*
Total Registration Fees*
Please type the TOTAL amount collected for this event. (Registration fee X Number of Registrants). DO NOT type the $ sign.
Cost Recovery Amount Total*
Please type the amount of the deposit being sent to Cash Management. ($10 per person or !0% of the total, whichever is greater.) DO NOT type the $ sign.
Comments
Email*
Enter Email Confirm Email

Please enter the email address of the person you want your confirmation summary to go to. (agent or support staff)
Email
This field is for validation purposes and should be left unchanged.

District 4 Administrative Services