Reimbursement Request – NSPA

Instructions

Please complete this form when seeking reimbursement from NSPA for approved expenses. Reimbursement may take up to 60 days processing and delivery. A copy of this form will be presented once submitted.

General Information

Name

First Last

Organization

Who should the check be made out to?

The submitter
The organization
WVEMS Vehicle Reimbursement

Address

Street Address Address Line 2 City State ZIP Code

Email

Type of Reimbursement Requested

Type of Reimbursement

Travel

Use the plus button (+) to the right to add days to the form.

Itemized Expenses

Date (MM/DD/YY)	Destination/ Location	Mileage (in miles)	Hotel (in dollars)	Per Diem (in dollars)

For per diem calulations, please visit http://www.gsa.gov/portal/content/104877

NDLSF Instruction

Itemized Expenses

Date (MM/DD/YY)	Type of Course	Sections Taught	Mileage (in miles)	Hotel (in dollars)	Per Diem (in dollars)

For a per diem calulations, please visit http://perdiem.vccs.edu/ (only applicable with overnight stay)

Other Expenses

Itemized Expenses

Date (MM/DD/YY)	Description of Expense/Item	Amount (in dollars)

Supporting Documentation

Attestation*

Submitting is Your Signature

I hereby attest that the above request for reimbursement is accurate and complete to the best of my knowledge and agree that NSPA has the right to refuse any amount/expense deemed ineligible by policy, regulations, and/or law.