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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
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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
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