Department of Labor and Industries Claims Section PO Box 44269 Olympia WA 98504-4269 Plan Room And Board Cost Encumbrance Modified Early Termination Original Revised This form contains auto calculations Date Billing Codes Vendor Name Provider # Dates of Service Board - R0360 (Food & Utilities) Housing - R0370 (Rent & Furniture) Relocation - 0375R (1 time per claim) Sub Total Worker Name Claim # From To From To From To From To $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 Page 1 Total $ 0.00 Please attach an approved copy of this form to the Statement for Retraining and Job Modification Services form when submitting bills. Per diem for housing, R0370, is calculated for the county in which the training site is located. When billing includes refundable cleaning fees and/or start-up fees, the vendor(s) is reminded that any/all of the refund is to be returned to the Department of Labor and Industries. Vendor: Please include a copy of this approved form with your refund. Room and Board can be paid up to 29 days before the plan start date. Self-Insured Claims (to be provided by the insurer) Refund Mailing Address only: State Fund Claims Attn: Cashiers Office Department of Labor and Industries PO Box 44835 Olympia WA 98504-4835 Vocational Provider Assigned VRC Name Firm Provider # VRC Phone # Department Use Only VSS Signature Approved Signature Branch # VRC Fax # VRC # Date Not Approved F245-372-000 Plan Room and Board 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 Room And Board Cost Encumbrance Modified Early Termination Original Revised This form contains auto calculations Date Billing Codes Vendor Name Provider # Dates of Service Board - R0360 (Food & Utilities) Housing - R0370 (Rent & Furniture) Relocation - 0375R (1 time in life of claim) Total Worker Name Claim # From To From To From To From To $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 Page 2 Total $ 0.00 $0.00 Plan Grand Total Please attach an approved copy of this form to the Statement for Retraining and Job Modification Services form when submitting bills. Per diem for housing, R0370, is calculated for the county in which the training site is located. When billing includes refundable cleaning fees and/or start-up fees, the vendor(s) is reminded that any/all of the refund is to be returned to the Department of Labor and Industries. Vendor: Please include a copy of this approved form with your refund. Room and Board can be paid up to 29 days before the plan start date. Self-Insured Claims (to be provided by the insurer) Refund Mailing Address only: State Fund Claims Attn: Cashiers Office Department of Labor and Industries PO Box 44835 Olympia WA 98504-4835 Vocational Provider Assigned VRC Firm Provider # VRC Phone # Department Use Only VSS Signature Approved Branch # Signature VRC# VRC Fax # Date Not Approved Index: VPLAN American LegalNet, Inc. www.FormsWorkFlow.com F245-372-000 Plan Room and Board Cost Encumbrance 02-2015 Page 2 of 2 (Do not print page 2 if blank)