Indiana Volunteer Firefighter’s Association, Inc.

LOST CLOTHING VOUCHER

Each request must be filled out and signed by the Claimant and Fire Chief or Fire Department Secretary.  Make a copy for your records and forward the original completed form to the your District Chairman of the I.V.F.A.  All information requested must be completed.  Claims shall be presented to the District Chairman within 60 days of loss to be valid.  Do not destroy damaged articles until claim has been settled.

 

                                                                                                                                                                                                               

            Name of Fire Department                                                            City or Town                              County                  District #

 

                                                                                                                                                                                                               

        Name of IVFA Member                                                 IVFA Membership #

 

                                                                                                                                                                                                               

            Address of IVFA Member                                             City or Town                           County                     Zip Code

 

                                                                                                                                                                                                               

            Date of Loss                                                                                Place of Loss and Address

 

                                                                                                                                                                                                               

            Article Damaged  (pants, shirt, glasses, and etc.)

 

                                                                                                                                                                                                               

            Date Article Purchased (Month/Year)                          Cost of Article When Purchased $

 

I do hereby certify that to my knowledge that this request is true and accurate as filed, which is not more than $100.00 for clothing or more than maximum allowance for the damage of eye glasses or contact lenses is limited to fifty dollars ($50.00) except in the case of hearing aide in connection with eye glasses, where a maximum allowance is limited to seventy-five dollars ($75.00).  Clothing Committee meets quarterly, February, May, August, November.

 

                                                                                                                                                                                                               

                                Signature of Claimant                                                                               Date

 

I, Fire Chief Ś or Secretary Ś have checked the above request and recommend to the I.V.F.A. Treasurer this claim be paid in accordance with the SOG’s of the I.V.F.A.                                                                                                          

                                                                                                                Signature of Chief or Secretary of Fire Dept.            Date

For Clothing Committee Use Only

 

Amount requested by IVFA Member                                                                               $                                             

 

Amount of Value Per Dry Cleaners Form                                                                         $                                             

 

Amount Paid IVFA Member                                                                                              $                                             

 

Description of Loss and Disposal of Article                                                                                                                  

 

                                                                                                                                                                                               

 

                                                                                                                                                                                               

 

 
 
 

 

 

 

 

 

 

 

 

 

 

 

 

 


Further Remarks Regarding Claim:                                                                                                                                                 

 

                                                                                                                                                                                                               

 

Signature I.V.F.A. District Chairman                                                    Date                                                                    

                                                                                                                                                               

Date Reported to the I.V.F.A. Treasurer:                                            Date Claim Paid                   Ck #                     

                                                                              Month/Day/Year

 

Lost Clothing Voucher.doc

Revised 2/1/03