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EXHIBIT D <br />Juvenile Court Evidence Based Expansion <br />MONTHLY REIMBURSEMENT REQUEST FORM 5FY24.25 <br />Attach completed Form(s) to an lnvoice Voucher Form (A-19) when submitting requests for payment <br />to JR. Note: Complete a separate MONTHLY REIMBURSEMENT REQUEST FORM for each type of <br />intervention (FFT, MST, COS and EET). <br />COUNTY MONTHiYEAR INTERVENTION P <br />(FFT, MST, ETC.) <br />ROGRAM <br />COSTS THIS MONTH <br />Department of Children, youth & Families <br />2017CF County Program Agreement 6-24-20 <br />$_ <br />$ <br />$ <br />$ <br />A ministrative not ceed 1 $ <br />TOTAL COST $ <br />Page 1 8