First 52 Week Period Training Plan Cost Encumbrance
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First 52 Week Period Training Plan Cost Encumbrance Form. This is a Washington form and can be use in Claims Workers Comp.
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Tags: First 52 Week Period Training Plan Cost Encumbrance, F245-354-000, Washington Workers Comp, Claims
1st 52 WEEK PERIOD
Department of Labor and Industries
This form must be completed by the Vocational
Counselor assigned by either State Fund or
Self Insurance.
**** Counselor is responsible for sending
a copy of this form to each vendor ****
TRAINING PLAN COST ENCUMBRANCE
Claimant:
Date
Vendor Name
Billing Category
and Code
Modification
Original
Vendor Name
Vendor Name
Claim Number
Vendor Name
Provider No.
Provider No.
Provider No.
Provider No.
From:
To:
From:
To:
From:
To:
Expended Funds
per RVRE:
(attach copy)
Total
Funds
From:
To:
Travel - R0330
Tuition - R0310
Books - R0340
Equip - R0315
Supplies - R0312
Licensed
Child Care - R0390
Other - R0350
Vendor Funds
Allocated
»
Dates of Service
» » » » » » » » » » » » »
Total Training Funds Allocated 1st 52 Weeks:
NOTE:
When vendor funds are reduced, the VRC must contact vendor to:
1) Make sure all billings are submitted and paid.
2) Notify the vendor that the amount authorized will be reduced.
3) Provide the vendor with a copy of the approved modified encumbrance form.
Company
Phone No.
Assigned Vocational Counselor:
Date
FAX No.
Signature
For Dept Use Only
Vocational Services Specialist
Not
Approved
Approved
Date
Phone No.
F245-354-000 1st 52 wk tng plan cost encumbrance 01-2008
For workers with training plans approved after 1-1-2008, use form F245-374-000
Signature
INDEX: VPLAN
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