Alternate Receipt for DVR Services

Document Number:  DVR-13813-E

Description:  This form is completed by consumers when they are unable to provide receipts or an Expense Reimbursement Log (ERL).

Comments:  Form is protected from modification and enabled for form fill (includes tabbed fields for form completion).

Content Contact:  Audrey Merten

Document Attachment:  DVR-13813-E (Word/39 KB)

*** If you need to access this form in an alternate format, please send an email to the Content Contact listed above.

*** Should you require the necessary software to view the above attachment, please go to the DWD Viewers Download Page.  Links to each specific vendor's site have been provided for you.  Thank you.