Financial Request Form

Name

Address

City

State

ZIP

Phone

Name of Event

Address of Event

City

State

ZIP

Date of Event

Arrival Date

Departure Date

Estimated Total Amount of Reimbursement Request

*MAXIMUM REQUEST AMOUNT FOR FULL MEMBERS: $1,500*
*MAXIMUM REQUEST AMOUNT FOR ASSOCIATE MEMBERS: $500*

Breakdown "Estimate"

Air Fare

Meals

Other

Other Description

Mileage

Lodging

Equipment

*MUST SUBMIT EXPENSE REPORT AND CORRESPONDING RECEIPTS FOR EACH BREAKDOWN ESTIMATE WITHIN 30 DAYS AFTER THE EVENT*

Personal Care Attendant (PCA) Information

Name

Address

City

State

ZIP

Phone

VA Approved Caregiver

Yes

PLEDGE & RELEASE OF LIABILITY

I have read and hereby agree to the terms of the PVA-WI’s Sports & Travel Policies and Procedures. 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):

Amount

Source

Signature (Full Name)