InstructionsPlease 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 InformationName 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 AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Type of Reimbursement RequestedType of Reimbursement(select a type of reimbursement)TravelNDLSF InstructionOther ExpensesTravelUse the plus button (+) to the right to add days to the form.Itemized ExpensesDate (MM/DD/YY)Destination/ LocationMileage (in miles)Hotel (in dollars)Per Diem (in dollars) For per diem calulations, please visit http://www.gsa.gov/portal/content/104877NDLSF InstructionItemized ExpensesDate (MM/DD/YY)Type of CourseSections TaughtMileage (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 ExpensesItemized ExpensesDate (MM/DD/YY)Description of Expense/ItemAmount (in dollars) Supporting DocumentationSupporting DocumentationMax. file size: 100 MB.Supporting DocumentationMax. file size: 100 MB.Supporting DocumentationMax. file size: 100 MB.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.