Speaker's Cash Request Form

This form should be used by a speaker after presentation to request payment for event.

Speaker's Name

Email Address

Address

City

State

Zip Code

Country

Date of Talk

Title of Talk

Sponsoring Organization

Estimated Audience Size

City traveled from

City traveled to

Total miles traveled to and from talk site

Amount of miles x $0.50 =

An in-kind (non-cash) match of $175.00 for your time and miscellaneous expenses is automatically assumed. This match fulfills KH/NEH program requirements.

Honoraria

Food (Maximum amount reimbursed: $5 breakfast, $8 lunch, $16 dinner)

Receipts for amounts over $5.00 required. You may mail the receipts in or scan and email to zoe.kaylor@uky.edu.

Other reimbursements (i.e., tolls,). Please specify

Total amount requested

Please describe audience. Was it old or young, male or female, caucasian or African-American, etc.

General composition of Audience

Were the local arrangements satisfactory, and as agreed upon between you and the sponsoring organization?

How would you describe the audience's response to your presentation?

Did the audience participate in the discussion?

Do you consider the program successful or unsuccessful?

Why did you consider the program successful or unsuccessful?

Was Kentucky Humanities recognized or credited for this presentation?

If recognized, please explain how

Other comments