A copy of this form will be kept on file by the Business Administrator – 9/00
University of Pennsylvania
School of Medicine
Policy Number: Fin IS- 001
Remote Access Charges
Annual Reimbursement Attestation statement. This procedure is developed in
accordance with the School of Medicine policy – Remote Access Charges (Fin IS –001).
Please refer to the written policy for specific details and guidelines.
This form is to be used by those faculty and staff who wish to request annual
reimbursement for monthly remote access subscriber fees associate with Penn mission-
related work activities requiring access to networks and systems while away from the
Penn campus. Reimbursement applies strictly to the percentage of the monthly subscriber
fee for which the faculty member attests. The amount of the chair/director authorized
reimbursement may be capped at their discretion. Other expenses related to the
installation of service or equipment is strictly the responsibility of the faculty member.
The accuracy of the information is the sole responsibility of the faculty person whose
signature appears below.
Only non-federal monies, that do not have any restrictions prohibiting such use, can be
used within a department to support this reimbursement request. As stated in the policy,
the cost of such services is not an allowable cost on federal grants according to OMB
Circular A-21.
Reimbursement for remote access subscriber fees will be paid through the associated
department annually prior to the end of the fiscal year (June).
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I certify by my signature below that I am accurately representing my use of my remote
access subscription and my request for reimbursement for remote access fees paid reflects
the proper percentage of my total monthly fees of $_________. (Reimbursement will be
calculated by multiplying the percentage used times the monthly subscriber fee.)
Check one:
q
10%
q
25%
q
50%
q
75%
q
100%
__________