Workers222 Compensation Division Preferred Worker Program Placement Payment Request See OAR 436-110-0345(4) for more information. If you have questions or need more help, contact the Preferred Worker Program in Salem, 503-947-7588; 800-445-3948 (toll-free); fax 503-947-7581. Worker n ame: Counselor/contractor n ame: WCD no.: Federal Tax ID no. Person completing form: Mailing address: Phone: City, state, ZIP: Fax: Instructions (see page 2 for helpful information) 1) Refer to the Placement Assistance Agreement for relevant information. 2) Attach a legible, detailed invoice for services provided. 3) List travel time as a separate line item. 4) All requests must be made within one year of end date of Placement Assistance Agreement. 5) Fax a copy of this request and all supporting documents to 503-947-7581, or email to PWPSupportWork.WCD@oregon.gov . I am requesting payment for the following services provided : Placement assistance services listed on the attached invoice Employment p lacement $500 (subject to verification) 30 - d ay employment r etention i ncentive $500 (subject to verification) If request is for employment placement payment or 30 - day employment retention incentive payment , provide the following: Hire date: Employer name: Contact person: Phone number: By my signature, I agree that the above information and supplemental documentation is correct to the best of my knowledge. Counselor/c ontractor signature Certification no. , if applicable Date 440 - 5135 (1/17/DCBS/WCD/WEB) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com How do I get paid? There is an end date listed at the bottom of the Placement Assistance Agreement. You must request all of your reimbursements no later than one year after that end date. Invoices submitted for placement assistance services must include specific services provided and time spent working directly with the worker. Travel time must be listed separately. Payment for placement assistance services are based on a billable hourly rate of $85. Payment for travel is $42.50 per hour. The 30-day employment retention incentive payment only applies if the worker maintains employment for 30 or more days with the same employer that the job placement was made. Services provided, hire date, and employer eligibility will be verified by the Workers222 Compensation Division. The more complete the information you provide, the quicker payment can be made. If electronic transmission of documents if not an option, you may mail all requests and documentation to: Preferred Worker Program Workers222 Compensation Division 350 Winter St NE P.O. Box 14480 Salem OR 97309-0405 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com