Department of Labor and Industries This form must be completed by the Vocational Counselor assigned by either State Fund or Self Insurance. TRANSPORTATION COST ENCUMBRANCE Original **** Counselor is responsible for sending a copy of this form to each vendor **** Modification Revised Claimant: Date Vendor Name Vendor Name Claim Number Vendor Name Vendor Name Total Funds Billing Category and Code Provider No. Provider No. Provider No. Provider No. Mileage - 0301R $0.00 Parking - 0302R $0.00 Bridge & Ferry Tolls - 0303R $0.00 Commercial Transportation - 0304R $0.00 Vendor Funds Allocated $0.00 Dates of Service $0.00 From: To: $0.00 From: To: » » » » » » » » » » » » » $0.00 From: To: From: To: $0.00 Total Transportation Funds Allocated: Mileage Calculation Address training site A Address training site B 1st, Miles in a round trip (Worker's street address to site A by most direct route). 2nd, Multiply miles by the actual x training days. 1st, Miles in a round trip (Worker's street address to site B by most direct route). 2nd, Multiply miles by the actual x training days. 3rd, Multiply total in line 2 by current reimbursement rate x 3rd, Multiply total in line 2 by current reimbursement rate x Reimbursement to site A = Reimbursement to site B = Reimbursement to site A 0.00 Total reimbursement requested (Site A+Site B) = NOTICE: Please attach a copy of this form to the Injured Worker's Travel Expense Voucher form (yellow), when submitting for reimbursement. Company Phone No. Assigned Vocational Counselor: Date FAX No. Signature For Dept Use Only Vocational Services Specialist Not Approved Approved Date Phone No. F245-375-000 transportation cost encumbrance 01-2008 For workers with training plans approved before 1-1-2008, use form F245-360-000 Signature INDEX: VPLAN American LegalNet, Inc. www.FormsWorkflow.com