Washington > Workers Comp > Crime Victims Compensation

Travel Reimbursement Request (Crime Victims) F800-049-000 - Washington

Travel Reimbursement Request (Crime Victims) Form. This is a Washington form and can be used in Crime Victims Compensation Workers Comp .
 Fillable pdf Last Modified 10/27/2011
Get this form for FREE as a print-only pdf

Mail completed forms to: Crime Victims Compensation Program Department of Labor & Industries PO Box 44520 Olympia WA 98504-4520 TRAVEL REIMBURSEMENT REQUEST Claim No. Date of crime injury Apt # State ZIP Social Security No. (for ID only) Phone no. · Read the instructions on the next page before you start. Victim Information (Please print) Name (Last, First, Middle Initial) Home address (not PO Box) City Travel Information ­ Instructions and example on next page. A. B. C. D. E. F. G. Date (each trip) mm/dd/yyyy 1. 2. 3. 4. 5. 6. 7. Travel code (one per line see next page of form) From (city where you lived) To (city) Provider name & reason for visit No. of miles (round trip) Expense cost (one per line) Required: Signature of the person you saw. Date 1. Date 2. Date 3. Date 4. 7. 6. Date 5. Date Date Required: Victim's Signature These expenses are related to my victim's compensation claim and I have not been reimbursed for them. I understand it is a crime to submit information I know is false. I have read and understand the instructions on the next page of this form. Date Victim's name printed Victim's signature Instructions: complete each column. F800-049-000 (05-2011) American LegalNet, Inc. www.FormsWorkFlow.com · · · · · · · Column A: Date you traveled (one date per line). Column B: Use only one code per line. Codes are listed below. Column C: City where you lived on the day you traveled. Column D: City you traveled to. Column E: Provider you saw and reason for traveling. Column F: Total number of miles you traveled round trip. Column G: Dollar amount of each expense (food, lodging, fares, parking). Only one expense per line. Parking expenses under $10 don't require a receipt. You must attach copies of all receipts. All receipts must be itemized and legible. No credit card slips. Travel codes Expense Private vehicle mileage Parking Bridge & ferry toll Commercial transportation Taxi Lodging Breakfast Lunch Dinner Medical services 0401A 0402A 0403A 0405A 0414A 0406A 0407A 0408A 0409A Signatures Medical visits: The person you saw must sign to verify each visit date. Victim's signature: You need to sign the form for reimbursement. Example A. B. C. D. E. F. G. Date (each trip) mm/dd/yyyy 1. 2. Travel code (one per line) From (city where you lived) To (city) Provider name & reason for visit No. of miles (round trip) Expense cost (one per line) 03/05/2009 03/05/2009 0401A 0402A Olympia Seattle Dr. Smith; post-op visit 120 $15.00 Need more help or more information? Go to www.lni.wa.gov/ClaimsIns/CrimeVictims or call 1-800-762-3716. Or check WAC 296-20-1103. Independent Medical Examination travel? Or just need more forms? Go to www.lni.wa.gov/ClaimsIns/CrimeVictims and click on Forms & Publications for Crime Victims F800-049-000 (05-2011) American LegalNet, Inc. www.FormsWorkFlow.com
Link/Embed this Document
URL
Embed


Popular Searches

  1. eviction
  2. motion to vacate
  3. proof of service by mail
  4. pro hac vice
  5. dissolution of marriage
  6. petition for termination of parental rights
  7. visitation
  8. notice of hearing
  9. Ex Parte
  10. dismissal

Bookmark and Share