Dvr-14157 - Witness Fee Expense Reimbursement printable pdf download

Dvr-14157 - Witness Fee Expense Reimbursement

Department of Workforce Development

State of Wisconsin

Division of Vocational Rehabilitation

WITNESS FEE EXPENSE REIMBURSEMENT

Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04 (1)(m), Wisconsin Statutes].

Witness on behalf of Impartial Hearing for the Division of Vocational Rehabilitation (DVR)

At: ____________________________________

Date: ____________________

(City Where Hearing Was Held)

To be reimbursed for witness fees, DVR needs the following information:

Name

Address

City & Zip Code

Left Home

(Date)

(Time)

Total Miles Traveled to Attend Hearing

(at $0.20 per Mile)

The Division of Vocational Rehabilitation will reimburse witnesses at $16.00 (full day) or

$8.00 (half day), plus $0.20 per mile. No reimbursement will be allowed for any other expenses

incurred (i.e., meals).

I ATTEST THAT THE ABOVE INFORMATION IS CORRECT.

Hearing Officer Name (Please Print)

Hearing Officer Signature

Date Signed

Form should be submitted to:

Impartial Hearing Coordinator

DVR Central Office

201 East Washington Avenue

Madison, WI 53707-7852

DVR-14157 (R. 02/2008)

Dvr-14157 - Witness Fee Expense Reimbursement