MO 500-2306i (1-07)
DEPARTMENT OF ELEMENTARY AND SECONDARY EDUCATION
DIVISION OF SCHOOL IMPROVEMENT
INTERNATIONAL BACCALAUREATE EXAM FEE REIMBURSEMENT
COUNTY DISTRICT CODE
SCHOOL DISTRICT NAME
CONTACT PERSON
WORK TELEPHONE
EXT.
MAILING ADDRESS
CITY
STATE
ZIPCODE
E-MAIL ADDRESS
FAX NUMBER
Assurances: The school district assures the Department of Elementary and Secondary Education that:
A: it will keep such records and provide information as may be necessary for fiscal and program auditing and for pro-
gram evaluation, and will provide the Department of Elementary and Secondary Education any information it may
need to carry out its responsibilities under the Missouri Fee Payment Program.
B: it will comply with all provision of the Missouri Fee Payment Program and all administrative rules of the Department
of Elementary and Secondary Education applicable to the project.
C: complete required College Board on-line ordering form.
The governing board, through its authorized representative, fully understands these Assurances and responsibilities for
compliance placed upon local education agencies (LEAs) by the Assurances. The LEA will refund directly to the Department
of Elementary and Secondary Education, or hereby authorizes the Department to withhold from the LEA's payment under
the state foundation program or other state-funded programs, the amount of any funds made available to the LEA which
may be determined by the Department or an auditor representing the Department to have been misspent or otherwise mis-
applied.
AUTHORIZED REPRESENTATIVE NAME
DATE
DIRECTIONS
Use this form for Federal fee requests. Enter the number of Juniors and Seniors for whom you are requesting reimbursement
in each subject area and registration fee. The totals will be completed automatically.
FEDERAL REQUEST
ENGLISH ($88 PER EXAM)
FOREIGN LANGUAGE ($88 PER EXAM)
MATHEMATICS ($88 PER EXAM)
SCIENCE ($88 PER EXAM)
SOCIAL STUDIES ($88 PER EXAM)
OTHER ($88 PER EXAM)
REGISTRATION FEE ($129 PER STUDENT)
TOTALS
JUNIORS
NUMBER OF STUDENTS
SENIORS
TOTAL
ESTIMATED AMOUNT FOR INTERNATIONAL BACCALAUREATE EXAM FEE PAYMENT - FEDERAL FUNDS
Note:
The district will receive a letter by the end of May informing them of the amount of actual reimbursement they will
receive. If you do not receive a letter by then, please call (573) 751-2453.
