VSA Payables/Refund/Reimbursement Form
VSA will arrange to issue checks around the second and fourth Thursday of each month based on the time stamp of the form. Please e-mail documentation to
with your name and amount in the subject line. For example, subject: John Doe - $99.00.
Last Name or Company Name
$ amount requested
include dollars and cents ... e.g., $25.14
Number of receipts
5 or more
Reason for request
If multiple items, state each one.
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