STIPEND CONTRACT
ED-47 (REV. 9/15)
I,
of
1
(complete name as it appears on your social security card or SS-4)
2
City
Mailing Street Address
agree to attend the following training given by the:
State
Zip Code
WV Department of Education
(organization name)
at
3
(training location)
4
(brief description of training event - if WV certified teacher, please state in this section and complete certification below)
5
Date(s) of training:
From:
The stipend shall be $
The stipend shall be $
The stipend shall be $
To:
per6
per7
per8
0.00
0.00
0.00
0
0
0
not to exceed $
not to exceed $
not to exceed $
0.00
0.00
0.00
10
Authorized Travel Expense 9: (check only one box)
Total: $
Will not be reimbursed.
Will be reimbursed upon proper documentation in accordance with the travel
regulations of the Agency not to exceed $
0.00
.
Please check the appropriate box below 11 (check only one box)
I am not currently a full-time employee of the State of West Virginia or a county board of education.
I am currently a full-time employee of the State of West Virginia. - Complete Certification 1
I am currently a full-time employee of
BOE - Complete Certification 2
(enter county name)
WV DEPARTMENT OF EDUCATION
VENDOR
Authorizing Signature12
1
Vendor’s Signature14
Date13
Date15
Printed Name16
Taxpayer Identification Number (SSN/FEIN) 17
Originating Office Name
Office of Internal Operations
CERTIFICATION: Full-time employees of the State of West Virginia must complete.
It is hereby certified that the stipend to be received under this contract will not interfere with or detract from the full-time duties of the employee.
The amount of annual compensation received by
(above named vendor) from the State
of West Virginia for full-time employment during the current fiscal year will be $
The vendor serves as
with the title of
(position)
(title)
Signature of Vendor’s Supervisor/Agency Head
2
Title
Agency Name
CERTIFICATION: Full-time employees of the WV Boards of Education must complete.
We certify that the time period covered under this contract is one of the below – check only one box: (Employee is REQUIRED to sign below)
That there is no compensation for the services covered by this contract (i.e. travel only)
That the services covered by this contract occur outside the hours in which this employee receives compensation; or
That both this employee and our organization are in compliance with Title 158, Series 14, regarding the filing of verified time records –
(If you check this box, then supervisor MUST also sign)
(Signature of Employee’s Supervisor)
(Signature of Employee)
WVDE USE ONLY
Document ID #:18
Acct:
Program20
Vendor 19#:
Check here if approval is required by the Attorney General.
1 Enter the individual’s name who will be attend ing/participating in a wor ksh op, conference, meeting, etc. If person is prov iding a service, please use ED-48 Service Con tract.
2 Enter the remit to address where indiv idual receives mail.
3 Enter the training location.
4 Enter a brief description of the event in which y ou are attending /participatin g.
5 Enter the stipend dates here. The stipend provided under this contract HAS to fall within these referenced dates, including travel dates. If this specific st ipend is required for a period of a y ear within a grant fund ing period, y ou can use one s tipend contract for the full y ear. If this is the case, in the “no t to ex ceed $0.00” section, enter ‘o pen end’ instead of the $ amount.
6 Acceptable: per hour, per day , per speech, per training session , per unit completed, etc. Unacceptable: per invo ice, per contract, per agreement.
7 Acceptable: per hour, per day , per speech, per training session , per unit completed, etc. Unacceptable: per invo ice, per contract, per agreement.
8 Acceptable: per ho ur, per day, per speech, per training sess ion, per unit co mpleted, etc. Unacceptable: per inv oice, per contract, per agreement.
9 Enter an X in the appropriate bo x. If travel is to be reimbursed under this co ntract, please estimate the maximum amount to be paid.
10 Enter the to tal from the above stipend line items. (<=$5000) signed by Office Director or Division Chief; (>$500 0 throug h $10,0 00) initialed by Office Director and signed by Division Chief; (>$10,000 through $25,000) initialed by Office Director and Division Chief; then, sig ned by Chief of Staff; and (>$25,000) initialed by Office Director, Division Chief, and Chief of Staff; then, s igned by State Superintendent. .
11 Enter an X in the appropriate bo x.
12 (<=$5000) signed by Office Director or Division Chief; (>$5000 through $10,00 0) initialed by Office Director and signed by Divisio n Ch ief; (>$10,000 through $ 25,000) initialed by Office Director and Division Chief; then, signed by Chief of Staff; and (>$25,0 00) initialed by Office Director, Division Chief, and Chief of Staff; then, s igned by State Superintendent
13 Enter date of signature.
14 Signed by ind ivid ual lis ted on this form; or, if agency , signed by a representative. If agency , be sure to list bo th agency and representative name in the top section as indicated.
15 Enter date of signature.
16 Ty pe name of authorizing signature.
17 THIS FIELD MUST BE COMPLETED. If indiv idual, SSN ; if agency , FEIN number.
18 If ED-4 was completed, enter the assigned Docum ent ID #. If no ED-4 was completed, then the Finance Office will complete.
19 Originatin g office will insert vendor number.
20 Enter Program. Example: 03CXR.0
21 Enter PPC - fiscal y ear which services are rendered. Example F2015 or S2 015
22Enter Unit: E xample: 0025
23Enter Fund. Example: 0313
24Enter Approp. Example: 1300 0

Approved:
PPC21
Unit22
Fund23
Approp24