Second 52 Week Period Training Plan Cost Encumbrance
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Second 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: Second 52 Week Period Training Plan Cost Encumbrance, F245-357-000, Washington Workers Comp, Claims
2nd 52 WEEK PERIOD
Department of Labor and Industries
TRAINING PLAN COST ENCUMBRANCE
This form must be completed by the Vocational
Counselor assigned by either State Fund or
Self Insurance.
Claimant:
Date
Vendor Name
Vendor Name
Modification
Original
**** Counselor is responsible for sending
a copy of this form to each vendor ****
Vendor Name
Claim Number
Vendor Name
Expended
Funds per
RVRE:
Billing Category
and Code
Provider No.
Provider No.
Provider No.
Provider No.
Total
Funds
(Attach copy)
Travel - R0330
$0.00
Tuition - R0310
$0.00
Books - R0340
$0.00
Equip - R0315
$0.00
Supplies - R0312
$0.00
Licensed
Child Care - R0390
$0.00
Other - R0350
$0.00
Vendor Funds
Allocated
Dates of Service
$0.00
$0.00
From:
To:
$0.00
From:
To:
From:
To:
» » » » » » » » » » » » »
$0.00
From:
To:
Total Training Funds Allocated 2nd 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
Recommended
Phone No.
Signature
Date
Phone No.
Signature
Recommended
Supervisor of Industrial Insurance
Approved
Date
Not
Not
Approved
F245-357-000 2nd 52 wk tng plan cost encumbrance
01-2008
Do not use for workers with training plans approved after 1-1-2008
INDEX: VPLAN
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