PRSS SUD/MH Application, Testing, Retesting, and Recertification Refund Request Form
Use this form if you paid an application review, recertification, or testing/retesting fee on or after 9/30/2024 and are requesting grant funding to refund the fees. If your agency paid the fees directly to WVCBAPP, WVCBAPP will refund the AGENCY. Late/rush processing and PayPal fees are NOT refundable.
Name
*
First Name
Middle Name
Last Name
I am representing an agency asking for several reimbursements, and I have listed the transactions here :
Name, date, fee name
Did an agency pay for or reimburse you for any part of your application / testing process?
*
Yes, my agency paid in full
Yes, my agency paid partially
No, I paid all fees personally
My agency reimbursed me
I am an AGENCY requesting reimbursement for several individual fees.
Other
If other please explain:
Name of Agency that Paid the Fees
*
Type N/A if an agency did not pay or reimburse you for your fees.
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Requesting Refund for
*
PRSS SUD Testing
PRSS MH Testing
PRSS SUD Application Review Fee
PRSS MH Application Review Fee
Practice Exam Fees
PRSS SUD Retesting
PRSS MH Retesting
PRSS SUD Recertification
PRSS MH Recertification
Payment Date:
*
-
Month
-
Day
Year
Must be dated 9/30/2024 or later.
Payment Date:
-
Month
-
Day
Year
For use if you paid on different dates.
Payment Date:
-
Month
-
Day
Year
For use if you paid on different dates.
Upload ALL receipts, cancelled checks, or money orders
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Total Requested Amount
*
Do not include PayPay or Late/rush processing fees
Additional Notes
Submit
Should be Empty: