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Preparedness Exercise Reimbursement

PAYEE INFORMATION
Payee Name:		Submission Date:
Address:
City:	State:	Zip Code:
Phone:		Billing Period:
SAP Vendor No:		SSN/TIN No:

NOTE: Payee must have their Tax Identification Number (TIN) and the actual name associated with that TIN or the reimbursement will not be processed. An IRS Form W-9 Request for Taxpayer Identification Number and Certification shall be submitted with each invoice.

DESCRIPTION OF ACTIVITY (Only ONE Exercise per Form)
Date(s) of Exercise:	Exercise Name:
Location:
Exercise Type:	Exercise Scale:
Number of Service Participants:	Type of EMS Service:

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Preparedness Exercise Reimbursement