Skip main navigation

Outdated or Unsupported Browser Detected
DWD's website uses the latest technology. This makes our site faster and easier to use across all devices. Unfortunatley, your browser is out of date and is not supported. An update is not required, but it is strongly recommended to improve your browsing experience. To update Internet Explorer to Microsoft Edge visit their website.

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).  The print (pdf) version is available for viewing and printing only.

Content Contact:  DVR Forms

Document Attachments:

DVR-13813-E  (English Electronic Version - Word/41 KB)

DVR-13813  (English Print Version - pdf/26 KB)

Note: If you need this form in an alternate format, please send a message to the Content Contact listed above.