2nd 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. BOARD & ROOM COST ENCUMBRANCE Claimant: Date Vendor Name Billing Category and Code Modification Original **** Counselor is responsible for sending a copy of this form to each vendor **** Vendor Name Vendor Name Claim Number Vendor Name Total Funds Provider No. Provider No. Provider No. Provider No. From: To: From: To: From: To: From: To: Board - R0360 (Food & Utilities) Housing - R0370 (Room & Furniture) Relocation - 0375R (1 time/life of claim) Vendor Funds Allocated Dates of Service NOTICE: 1) Please attach an approved copy of this form to the F245-030-000 Statement for Retraining and Job Modification Services form (pink) when submitting bill(s). 2) Per Diem for Housing - RO370 is calculated for the County in which the training site is located. 3) 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 or to the self insurer. Please include a copy of this form with your refund. Refund Mailing Addresses: State Fund Claims: ATTN: Cashiers Office Department of Labor and Industries PO Box 44835 Olympia WA 98504-4835 Company Self Insured Claims (to be provided by Insurer): Phone No. Assigned Vocational Counselor: Date FAX No. Signature For Dept. Use Only Vocational Services Specialist Not Recommended Recommended Supervisor of Industrial Insurance Not Approved Approved Date Phone No. Signature Date Phone No. Signature F245-358-000 2nd 52 wk bd & rm cost encumbrance 01-2008 Do not use for workers with training plans approved after 1-1-2008 INDEX: VPLAN American LegalNet, Inc. www.FormsWorkflow.com