VSUW Quality First Scholarships Program FY21 Monthly Reporting Phone: 602-240-6325

QT Targeted Pre-K Full TimePT Navajo Nation3QTFT

FTF ID: Street Address:

Site Name: City

State, Zip:

Phone Number: Site Contact

Person:

Email Address:

Reason for Adjustment:

Source (select one):

Participant Request

Quality Assurance

Signature Date

Date Last AttendedChild’s Name

First Date

Attended

Vacate Date

Scholarship Award

Adjustment

Amount

(Internal Use O

nly)

# of AttendedD

ays

# of Scheduled D

aysVacate Reason

# of Scheduled H

ours

FY21 Scholarships Adjustment Form

ADJUSTMENT MUST BE SIGNED BEFORE SUBMITTING.UNSIGNED OR INCOMPLETE FORMS WILL NOT BE ACCEPTED.

I certify that the information reported on this form is accurate and complete:

Upload completed form to Scholarships Reporting Potal - www.azftfscholarships.org > Documents tab > Document Type "Adjustment"

Date of Birth

# of Absences

Adjustment Month

Notes:

Final R

eimbursem

ent