*MUST SUBMIT EXPENSE REPORT AND CORRESPONDING RECEIPTS FOR EACH BREAKDOWN ESTIMATE WITHIN 30 DAYS AFTER THE EVENT*
PLEDGE & RELEASE OF LIABILITY
I have read and hereby agree to the terms of the PVA WI Program/Benefit Policies and Procedures Manual. I understand if I do not complete the requirements, I may not be eligible for future financial assistance from the PVA-WI until I have complied with the requirements.
If I am receiving additional funding from another source for this event, I am disclosing this information (if not applicable entering "0" or "N/A" is acceptable):
