Reimbursement Receipt / Closing Notification

SED API version: 0.16.2 build 2
Model version: 4.2.0

Local case numbers

Local Case Number

Country *

Case number *

Institution

Institution ID *

Institution Name *

Local Case Number

General information *

Reimbursement request ID *

Reimbursement payment notification ID *

Reimbursement receipt or closing notification ID *

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Amount received *

Amount *

Currency *

Date of payment received *

Reimbursement request closed *

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Please fill in the following if "Reimbursement request closed" = "No" :

Reason for not closing reimbursement request

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Please fill in the following if "Reason for not closing reimbursement request" = "99 - Other reason" :

Reason

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