PRSS SUD 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 03/05/2026 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 PRSS-MH 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.
Format: (000) 000-0000.
Requesting Refund for
*
PRSS SUD Testing
PRSS SUD Application Review Fee
PRSS SUD Retesting
PRSS SUD 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
Terms and Conditions
Terms and Conditions
Submit
Should be Empty: