Department of Labor and Industries Claims Section PO Box 44269 Olympia WA 98504-4269 Plan Transportation Cost Encumbrance Modified Claim # Early Termination Original Date Revised Worker Name This form contains auto calculations Worker Address (Trip start) Vendor Section Vendor Provider # Vendor Name Billing Codes Parking 0302R Bridge/Ferry Tolls 0303R Commercial Transportation 0304R Cost Subtotal Dates of Service A B C D $ 0.00 $ 0.00 $ 0.00 $ 0.00 From To A B C D $ 0.00 From To $ 0.00 From To $ 0.00 From To Cost Total $0.00 Mileage Calculation 0301R Training Site Address, City, State (Trip end) # of round trip miles for most direct route; round to next highest mile. # of training days Vocational Provider Assigned VRC Name Firm Provider # VRC Phone # Department Use Only VSS Signature A B C D Costs in this section will be totaled by L&I Signature Branch # VRC Fax # Date Approved Not Approved VRC # F245-375-000 Plan Transportation Cost Encumbrance 09-2015 Index: VPLAN American LegalNet, Inc. www.FormsWorkFlow.com