Fill and Sign the 1st 52 Week Period Training Plan Cost Encumbrance Washington Form

Original                                                                       Billing Category                   and Cod                                                                                                 ~ Tuition - RO                  Books - R0340                   L Equip - R0315                                     upplies - R0312                                                            I Other - R035                                                                                                       Dollar Amount Recalled: $             , and Code:                                     ~-                                                      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 TRAINING PLAN COST ENCUMBRANCE ... **** Counselor is responsible for sendinga copy of this form to each vendor **** Modification I Claimant: - Date Claim Number Vendor ?4ame Vendor Name Vendor Name Vendor Name --I,-, Previous - T- r- I I st 52 Week Tota l I Pla n L&I I der No. Travel - R03 ( - I - I - hild Care - R0390, Vendor Fund - I Allocated es of Serv From: rom: To: To: I - >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> Total L&I Training Funds Allocated 1st 52 Weeks: .1. - __j * Vendor Funds Allocated: This is the total amount of funding available to the vendor within the stated dates of service: This total may change when additional funds are allocated or if they are recalled (due to a need to use the funding to meet other training needs). Before funds are recalled, the vocational counselor must contact the affected vendor to determine whether there are any outstanding bills. Funds cannot be recalled if they have been spent or if the vendor has an outstanding bill that will be paid. ** Vendor signature: Some vendors require their signature to confirm there are no outstanding bills. Please obtain if required by the vendor. - . . Recall of Funds & Vendor Verification - - ... - , from Billing Category: I--Vendor Representative: Position- Date Contacted: - - Provider No. - i Vendor Phone No. Vendor FAX No. ' ** Vendor Signature -IL - - -------~ eason for recall: I I I -- I VocationaTCounselor: - Date Signature . . Company Phone No. - FAX No. ~'- . . - -11 For Dept Use Only . - . . I Claims Manager Date I Phone No. Signature '\ - F Disapproved - . ' ) F245-354-000 (FPDF) lst52 brance 8-00 INDEX: VPLAN