Claimant Information: Reimburse to (mark only one selection):
Squadron MN or Member CAPID or Vendor or Wing Credit Card
Reimburse to (Name): / / Sortie Date:
(Please Print) / Attach Mailing Label: / Mission Number:
Or Address: / WMIRS Entry Nbr:
City: / Telephone Nbr:
State, Zip: / e-mail:
Aircraft information:
/ Air Sortie Number:Aircraft number: / Aircraft type:
Hobbs Time
/Line
/Tach Time
/ LineStop: / 1 / Stop: / 4
Start: / 2 / Start: / 5
Hobbs Hours: / 3 / Tach Hours: / 6
Line 3 = line 1 – line 2 / Line 6 = line 4 – line 5
Mission Symbol: / 7 / Fuel cost: / $ / 13
Fuel used (gals): / Gals. / 8 / Oil cost: / $ / 14
Oil used (qts): / Qts. / 9 / Total Costs: / $ / 15
Departure Airport: / 10 / Pilot: / 16
Destination Airport: / 11 / IP/Observer: / 17
Assigned Area: / 12 / Scanner: / 18
Vehicle Information: / Ground Sortie Number:
Vehicle Make/Model: / 19 / Vehicle ID/License: / 23
Hours in Sortie: / 20 / Miles Driven: / 24
# of personnel: / 21 / Gallons of Fuel: / 25
Driver: / 22 / Fuel Cost: / $ / 26
Miscellaneous Information: / / / $ / 27
Comments, Remarks, and Explanation of Miscellaneous Costs*
28
*Lodging, Per Diem and Other costs require pre approval (Use back of form for additional explanation)
Please e-mail, fax or mail this COMPLETED form, with receipts, to Minnesota Wing. If there is more than one WMIRS sortie for a fueling and the Hobbs time is consecutive, a single cumulative 10v may be submitted for the sorties.
Mail:
Minnesota Wing, 108 Task Force
6275 Crossman Lane
Inver Grove, MN 55076 / Fax: 651-552-7007
E-Mail:
MNWG F10v May 2009 (Previous editions will not be used after 30 June 2009.) (LOCAL REPRODUCTION IS AUTHORIZED).