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)