Fill and Sign the 1st 52 Week Period Board and Room Cost Encumbrance Washington Form

Modification Original                                                                  and Code                         (Food & Utilities)                                                                                                                                                                                                                        Department of Labor and Industries This form must be filled out by a Vocational Rehabilitation Counselor who has received a referral from the State Fund. 1st 52 WEEK PERIOD BOARD & ROOM COST ENCUMBRANCE **** Counselor is responsible for sending a copy of this form to each vendor **** Claimant: I Date Claim Number . . I Previous Total I Billing Category . . I st 52 week L& I Provider No. Provider No. Plan Fund s 1 Expenditures - 1 1 4 1 Rent - R0370 -+-, . (Room & Furniture) . . 1 - - Relocation - 0375R(I time/life of claim Vendor Funds - - - Allocated - - - I I Dates of Service - To: To: - 9 To: I I - - - >>>>>>>>>>>>>>>>>>>>>>>>>> Total L&I Board & Lodging Funds Allocated 1st 52 Weeks. I \~ - - _1/ NOTICE: 1) Please attach a copy of this form to the Statement for Retraining and Job Modification Services form when submitting bill(s). 2) When billing includes refundable cleaning fees and/or start-up fees, the vendor(s) is/are reminded that any/all of the refund is to be returned to the Department of Labor and Industries. Please include a copy of this form with your refund. Refund Mailing address only: ATTN: Cashiers Office Department of Labor and Industries PO Box 44835 Olympia WA 98504-4835 Company I I U Approved Disapproved , k, - F245-355-000 (FPDF) I st 52 wk bd & rm cost encumbrance 8-00 INDEX: VPLAN