Department of Labor and Industries Claims Section PO Box 44269 Olympia WA 98504-4269 Plan Cost Encumbrance Original Revised Modified Early Termination This form contains auto calculations Date Billing Codes Vendor Name Provider # Tuition and Fees R0310 Books R0312 Equipment R0312 Supplies R0312 Licensed Child Care R0390 Other R0350 Subtotal Dates of Service Worker Name Claim # $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 From To From To $0.00 From To $0.00 From To $0.00 Page 1 Total $ 0.00 Vocational Provider Assigned VRC Name Firm Provider # VRC Phone # Department Use Only VSS Signature Approved Not Approved Date Branch # VRC Fax # Signature VRC # F245-374-000 Plan Cost Encumbrance 02-2015 Page 1 of 2 (do not print page 2 if blank) Index: VPLAN American LegalNet, Inc. www.FormsWorkFlow.com Department of Labor and Industries Claims Section PO Box 44269 Olympia WA 98504-4269 Plan Cost Encumbrance Original Revised Modified Early Termination This form contains auto calculations Date Worker Name Claim # Billing Codes Vendor Name Provider # Tuition and Fees R0310 Books R0312 Equipment R0312 Supplies R0312 Licensed Child Care R0390 Other R0350 Subtotal Dates of Service From To $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 From To $0.00 From To $0.00 From To $0.00 Page 2 Total Plan Grand Total $ 0.00 $0.00 Vocational Provider Assigned VRC Name Firm Provider # VRC Phone # Department Use Only VSS Signature Approved Not Approved Date Branch # VRC Fax # Signature VRC # F245-374-000 Plan Cost Encumbrance 02-2015 Page 2 of 2 (do not print page 2 if blank) Index: VPLAN American LegalNet, Inc. www.FormsWorkFlow.com