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RLB Program Claim Form
Contact Information
Name
First Name
Last Name
Member ID
*
Don't know your member identification? Find it on your RLB Program award letter.
Phone
*
Email
Verify Email
This claim is for
*
Select one. Please note that your claim must be approved, in writing, on your RLB Program award letter before it can be processed.
select one
Reimbursement for a service
Reimbursement for goods purchased
Date of service or purchase
*
Please file a separate claim for each approved service or purchase.
Number of approved service hours provided
*
If not applicable, enter 0.
Total cost of approved services
*
For hourly reimbursement, multiply the approved hourly rate by the number of service hours rendered.
Name of approved purchased item
*
Total amount approved for reimbursemet of purchase
*
Please attach related receipts or service ledger.
*
A cell phone snapshot with proof of date of purchase or service rendered is acceptable.
Mailing Address - Approved correspondence will be mailed to this address.
*
Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code