Bay Area Workforce Development Board. Supportive Service Policy

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1 Bay Area Workforce Development Board Supportive Service Policy Board Approved on January 22, 2015

2 Financial assistance in the form of supportive services monies is available to any participant enrolled in a WIA service component. The type and amount of support service will vary based on the needs of the participant, availability of funds and program participation. Support services are not an entitlement and may be reduced or eliminated upon notice. The support service is determined through the objective assessment process and properly documented on the participant s Individual Service Strategy/Employability Plan and Manage Assessment tab in ASSET. Support services are provided through a request from the WIA Case Manager and final approval by Bay Area Workforce Development Board s Fiscal Department. All request forms must be complete, accurate, typed, signed and dated before funds can be released. All forms for reimbursement must be received at the Bay Area Workforce Development Board s office within two (2) months after the cost was incurred. Failure to submit the reimbursement form within allocated timeframe may result in the authorization being voided. No funds will be available after grant close-out has been submitted. If a participant is eligible for W-2, DVR, TAA or any other program/agency that sponsors supportive services (Oneida WIA, Menominee WIA, etc.), he/she is not eligible for WIA support service dollars unless the case manager determines that support services are not available through the agency or there is still an unmet need. Based on availability of funds, supportive services are provided in this order: Primary services 1. childcare 2. transportation Secondary services 1. uniforms or attire required for a training program or employment 2. work related expenses such as eyeglasses, protective eye gear 3. testing fees 4. background check 5. lodging fees 6. housing assistance 7. follow-up services Veteran s priority of service will be administered in the provision of support services. Bay Area WDB SUPPORTIVE SERVICES POLICY Page 1

3 This policy applies to: The Adult, Dislocated Worker, and Youth Programs under Title I of the Workforce Investment Act (WIA) Workforce Investment Act special response grants, National Emergency Grants (NEG) All other grants administered by the Bay Area Workforce Board unless the grant specifically states an alternative support services process Supportive services are available to participants who: Have been identified as in need of supportive services and cannot get assistance from other sources, programs or agencies Have the need for supportive services identified on the ISS and ASSET Are participating in Intensive or Training Services approved by Bay Area Workforce Development Board (BAWDB) Youth participating in youth services, other than design framework Are unable to obtain support services themselves, through other community sources/programs or job center partner services Under no circumstances will support services be available for: Business capitalization Deposits such as rental deposits, equipment reserves, etc. Mortgage and car payments Vehicle repairs Retroactive costs that were not originally stated in the Individual Service Strategy Delinquent/late fees Reimbursement for expenses incurred prior to the approval of the support service Medical services including dental and transportation costs for medical appointments Insurance premiums Any other cost other than the list on page 2 of this policy Individual case managers will maintain a directory of community organizations, local and county programs, other government programs, faith based organizations and state and national assistance groups that could provide supportive services. These resources will be utilized prior to Workforce Investment Act funding of supportive services. All supportive services are provided on an individual basis and any deviation from this policy must be on a waiver basis submitted to the Bay Area Board staff for approval prior to the occurrence of cost. Bay Area WDB SUPPORTIVE SERVICES POLICY Page 2

4 CHILDCARE ASSISTANCE Authorization Childcare through BAWDB is not intended to provide the full cost of the child care. Childcare will be authorized on a first come, first serve basis. Should funding be limited Veterans Priority Provisions of the Jobs for Veterans Act (P.L ) will be implemented. Childcare dollars will be reserved by semesters. Childcare funds that are not needed by returning students will be made available to other participants. It is the responsibility of the case manager to notify BAWDB s Fiscal Department if dollars allocated for the school year will not be needed. Funding of summer school childcare will be dependent on available BAWDB dollars. Reimbursement No reimbursements will be paid for a provider under 18 years of age. No reimbursements will be paid for a provider that is a parent/legal guardian of the child. Reimbursements will not be paid for anyone residing in the participant s house. Reimbursements will be paid only for times that the participant is participating in the authorized activity. Reimbursement is only allowed for children 12 years and under. Childcare Registration Fees Reimbursements are allowed for childcare registration fees. Payment will be made to the childcare provider. Childcare Provider Participants requesting childcare will provide their case manager with the name, address and telephone number of each childcare provider and whether the provider is licensed or other (not licensed). Childcare providers must submit a current federal employer identification number or social security number prior to reimbursement for any cost. The case manager must submit a copy of the social security card of all individuals that do not have a federal employer identification number with the initial request for child care provision. Dollar amount paid to childcare providers will be provided to the IRS per federal law. It is the responsibility of the case manager to submit the required forms in a timely manner. See Childcare Procedures for specific detail. Childcare Agreement A participant requesting childcare support dollars must sign, date, review, and submit Childcare Agreement prior to utilizing the childcare assistance. (See Childcare Procedures for specific detail.) It is the responsibility of the participant to pay their childcare provider for any amount beyond the monthly payment limit. Bay Area WDB SUPPORTIVE SERVICES POLICY Page 3

5 Childcare Amounts In order to receive childcare, a minimum of six (6) credits must be carried by the student. A payment of $50.00 per credit will be paid up to a maximum of $1, per lifetime benefit per WIA participant. Lab/Childcare The following policy is in effect for students requesting childcare while attending lab classes: Dependent Care The lab must be required for graduation and not available as a regular class. The amount of hours funded for childcare will be based on the average time it takes to complete the required lab. The average hours will be based on information provided by the technical college. The student must use the Student Exception (Form E) as specified in Childcare Procedures and must be signed by the lab instructor and the student. Form E must accompany each month s invoice for childcare. Students are requested to take lab hours in between regular classes on days of regularly scheduled classes. A maximum of 18 hours per credit will be funded. Exceptions to this requirement will need to be requested via a waiver form and include the class schedule, family situation, and the reason why the extra hours are needed. Additional information may be requested prior to approving or denying the waiver. There will not be funding available for childcare for attendance in the basic skills lab. Dependent care will be available through a waiver request process submitted to BAWDB staff. The services available will follow the policy in place for childcare. Bay Area WDB SUPPORTIVE SERVICES POLICY Page 4

6 TRANSPORTATION ASSISTANCE Transportation reimbursement is secondary to childcare and subject to the following: Private Vehicle Use of a private vehicle is allowed by participants in WIA services. Participants using their own vehicle for travel to and from WIA programs will be reimbursed as follows: Round trip Daily Rate miles $ miles $ miles $ $20.00 Each participant is required to maintain a Participant Mileage (Form G) as specified in transportation procedures and provide it to his/her case manager for approval and forwarding to BAWDB. Actual mileage dates that costs were incurred and the participant s signature are needed on the form each month of transportation assistance is required to be submitted on its own form and cannot include multiple months of mileage on a single form. Additional forms should be used if the participant attends more than 18 days of school within a given month (both forms must be signed and completed). The participant must submit the mileage form to the case manager within two months after the occurrence of the cost. The case manager will submit the forms to BAWDB. Travel costs for individuals residing in the same household, related or not, with the same or a similar class schedule, will be limited to one of the individuals only. Public Transportation / Passes / Tokens Participants utilizing public transportation will be provided the fare on an as needed basis. The case manager will maintain a log documenting the disbursement of the fare. The log must be signed by both the case manager and the participant. The funding of the bus pass will be provided through the contractor s budget in their Workforce Investment Act contract. Participants without access to public transportation and who do not own a vehicle may be reimbursed for travel costs incurred by another person providing their transportation. The reimbursement is strictly limited to transport to and from WIA programs. The participant must maintain a mileage log that includes the signature of the person providing the transportation and dates. The log is submitted to the case manager for approval and the case manager will forward the log to the BAWDB. Payment will be made to the participant who then reimburses the transportation provider. Payment will be at the same rate as allowed for participants using their own vehicle. Bay Area WDB SUPPORTIVE SERVICES POLICY Page 5

7 Gas Cards Gas cards will be the last option for individuals who lack transportation funds and cannot use the direct reimbursement process. The rational for using this exception to the transportation process must be submitted as a waiver to the Program Operations Manager prior to purchase of the card. The case manager must note the need and basis for the use of the card. The process is: The case manager submits a transportation request using the support service form H for a gas card. The fiscal department of the board authorizes the support service and enters the amount in PAS. The fiscal department issues a voucher for the gas card. The transportation request form and voucher are sent back to the case manager who will purchase the card. The card must be a gas only card. The case manager will maintain a gas card log and the participant must sign the log that they received the card. The log will have the participant name, PIN, card amount and vendor. The log should have the gas card number on it. The contractor s fiscal department submits the voucher for payment. If there is not a vendor that will accept the voucher the contractor must advance the funds to purchase the card and invoice the board for the advance reimbursement. The invoice will be a separate transaction from the contract invoices that the vendor submits. The invoice must be accompanied by the receipt for the purchase of the card, the support service request form and log showing the delivery of the card. Gas cards are issued in $10 increments and the amount will depend on the miles to be traveled on average mile per gallon of 15 miles per gallon. The dollar limit on a card is $30. Any other amount must be requested via waiver. WORK-RELATED/PRE-EMPLOYMENT ASSISTANCE Work-related/pre-employment expenses can be provided to assist participants if needed to enter the labor force. The participant s case manager completes the WIA Supportive Service Other Expense (Form A) and submits it to BAWDB for approval. Additionally, supporting documentation must accompany the request and include (at a minimum) a certified written offer of employment from the employer and a list of items/equipment required for the position. Examples of Work-Related Expenses Special tools, equipment or work gear required to enter employment Maximum Limit $1200 per participant Clothing/Footwear Maximum Limit $200 annually Immunization/Physical Exams Maximum Limit $500 annually Testing Fees The test must be required for the entry into employment. The fee is determined by the testing agency and will be considered on a case by case basis. Criminal Background Check Maximum Limit $ per participant Bay Area WDB SUPPORTIVE SERVICES POLICY Page 6

8 Other Work-Related Expense Participants showing the need for other work-related expenses will be considered on an individual basis. The request is submitted to the BAWDB for consideration. Upon approval, the participant purchases the necessary work-related item(s) and submits the expense for payment to BAWDB. Return of Tools, Equipment, Work Gear Individuals receiving tools, equipment and/or work gear, are required to complete their program of study or maintain employment for six (6) months. Failure to do so will result in the forfeiture of the tools, equipment and/or work gear to BAWDB. Equipment collection, return, and appropriate documentation is the responsibility of the case manager. Reimbursement All approved work related expenses must have proper documentation (i.e. receipts, invoices, etc.) when submitted to BAWDB for reimbursement. Payment is made to the participant for the expense. TEST FEES ASSISTANCE Test fees at the completion of the program of study, application for state license, or entrance to a program is allowable. Workforce Investment Act case managers will issue a voucher for the test fee or if a voucher is not acceptable use their organization s payment process and invoice the Bay Area Board for the payment. UNIFORMS/ATTIRE REQUIRED FOR A TRAINING PROGRAM OR EMPLOYMENT Individuals needing uniforms, special attire for participation in training or for entry to employment may receive assistance from Workforce Investment Act funding. The needs assessment, proof of the requirement for the uniform or special attire, and the documentation that other funds are not available is required prior to the submission of the request or issuance of a voucher. Limitations will follow the work-related guide stated in this policy. HOUSING ASSISTANCE Assistance with housing will primarily be an option in the Youth Corrections program or the Adult offender program. The need for the assistance will be documented and provided upon initial release from the correctional facility. The basis for this supportive service is to establish a community base for the offender. Other options for housing, such as group homes, will be explored and should they be available the group housing will be utilized. The Workforce Investment Act assistance will be secondary to the Department of Corrections funds. The payments will be made directly to the vendor and the need documented monthly. Upon entry into employment the housing assistance will end. LODGING ASSISTANCE Lodging assistance is available when the individual s training site or test site is over the regular commute pattern. The process will follow the procedure for test fees. Options for payments would be in the following priority order: 1. The participant contacts the lodging site, brings the information to the case manager. The case manager must review the information make sure the costs are reasonable and necessary. At the point of approval by the case manager the participant will contact the lodging facility, arrange the stay and put the cost on their credit card. Upon completion of the training or tests the participant will submit proof of payment and completion of activity to the case manager. The case manager will enter a Bay Area WDB SUPPORTIVE SERVICES POLICY Page 7

9 voucher for payment and submit the voucher, the proof of payment and name, address of individual that will be reimbursed. 2. The participant does not have a credit card. The process will follow the process for payment of test fees using the contracting agencies credit card. 3. The last option should the two above not be available would be using the Bay Area Board s credit card. In this instance the case manager and participant would contact the board s fiscal department and make arrangements. Under no circumstance will reimbursement be made for anyone other than the participant. STATE RAPID RESPONSE/NATIONAL EMERGENCY GRANT Supportive Services through state rapid response grants will be guided by the established Bay Area WDB supportive services policy and procedures. Additional supportive services beyond the scope of current policy will be addressed on an individual basis per grant. The service must be identified in the grant agreement. All of the services will be delivered on a surveyed, needs-based assessment. Exceptions Waivers will be accepted after the start of the semester. Waivers will not be retroactive. Bay Area WDB SUPPORTIVE SERVICES POLICY Page 8

10 Addendum Non-WIA Projects The following supportive services are in effect for all non-workforce Investment Act projects. The attachments at the end of this policy will apply to each project. Supportive services are in place to provide eligible individuals with temporary assistance while engaged in specialized projects. The type of service will be dependent on the grant providing the funding and the cost limitations of the grant. All of the services will be directed through a case manager working with the individual requesting the assistance and be the need documented in the individual s service plan. The duration of the assistance will be based on the individual s ability to pay for the service and documented in the individual service plan. Each grant must have written agreement with BAWDB for the provision of supportive services. The following supportive services will be available to Department of Corrections clients: Offender services will be available to each client. The services allowable are anger management, AODA, family reunification services, mental health counseling and CGIP. This funding will be allowable to organizations certified to provide the service and will be in addition to these services being provided by the primary contractor. The primary contractor must procure the services through a competitive bid process unless authorized by BAWDB to sole source a vendor. Work supplies and pre-employment services are available under the Department of Corrections contracts. The assistance includes clothing, state identification card, driver s license, bus passes, transportation assistance and other supplies needed for employment. Vouchers for basic food items until the person is able to get to the food pantry and sign up for food stamps is allowable. Case managers are responsible for providing local food pantry information and assisting the processing of application for food share. Rent, security deposits and utilities are allowable under the contract. A maximum of two (2) months rent assistance is available. Additional rent assistance must have pre-approval by BAWDB. The security deposit must include a signed agreement by the landlord for the return of the deposit to BAWDB. No rental assistance is available if the landlord does not sign a hold harmless letter releasing BAWDB for any damages, claims or actions prior to the payment of the security deposit and rent. Rent and security deposits are reportable to the landlord as income and will be the responsibility of the contractor. Post-secondary training funds are available for the clients. Additional Supportive Services such as: household supplies, food, personal hygiene supplies, utilities, telephone, medical needs, and other documented personal items are acceptable. The Case Manager will be present for the purchase of all additional supportive services. All services must be tracked on a per client basis and be provided monthly to BAWDB. Bay Area WDB SUPPORTIVE SERVICES POLICY Page 9

11 SUPPORT SERVICE POLICIES SUMMARY Financial assistance in the form of supportive services monies is available to any participant enrolled in an approved Workforce Investment Act component. The type and amount of support service will vary based on the needs of the participant, availability of funds and program participation. Support services are not an entitlement and may be reduced or eliminated upon notice. The support service to be provided is determined through the objective assessment process and indicated on the participant s Individual Service Strategy/Employability Plan/Manage Assessment Tab in ASSET. Support services are provided through a request from the WIA Case manager and final approval by the Bay Area Workforce Development Board Fiscal Department. All request forms must be complete, accurate, typed, signed and dated before funds can be released. All forms for reimbursement must be received at the Bay Area Workforce Development Board s office within two months after the incurred cost. Failure to submit the reimbursement form within allocated timeframe may result in the authorization being voided. No funds will be available after grant closeout has been submitted. Based on availability of funds, supportive services are provided in this order: 1) childcare 2) transportation 3) work-related/pre-vocational expenses such as eyeglasses, protective eye gear 4) follow-up services 5) testing fees 6) uniforms or attire required for a training program or employment 7) housing assistance 8) background checks 9) lodging fees If a participant is eligible for W-2, DVR, TAA or any other program/agency that provides supportive services (Oneida WIA, Menominee WIA, etc.) he or she is not eligible for WIA support service dollars unless the case manager determines that support services are not available through other sources or there is still an unmet need. Veteran s priority of service will be administered in the provision of supportive services. I have received a copy of the Bay Area Workforce Development Board Supportive Service Policies and Procedures and will abide by the Support Service Policy. I attest that I am not eligible for the Workforce Investment Act supportive services that are being provided from any another program or agency. WIA Participant s Name (Please print) WIA Participant s Signature Date Case manager signature and verification that the support service policy was provided and reviewed with the participant whose signature appears above. Case Manager s Name (Please Print) Case Manager s Signature Date Bay Area WDB SUPPORTIVE SERVICES POLICY Page 10

12 The following forms are attachments to this policy: Form A Form A-1 Form B Form C Form C-1 Form D Form E Form F Form G Form H Form I Other Support Request Non-WIA Support Request Childcare Request Childcare Request Tax ID Letter Childcare Agreement Childcare Expense Student Exception Form Transportation Request Form Participant Mileage Gas Card Form Direct Reimbursement Bay Area WDB SUPPORTIVE SERVICES POLICY Page 11

13 Bay Area Workforce Development Board WIA SUPPORT SERVICE WORK RELATED SUPPORT EXPENSE FORM A PARTICIPANT REQUEST/APPROVAL FUNDING SOURCE: Please select one JOB CENTER: Please select one PARTICIPANT S NAME: ADDRESS: CITY: STATE: ZIP: PHONE: ( ) PIN TYPE OF SUPPORT SERVICE NEEDED Items Needed (Specify) Cost Vendor $ $ $ $ TOTAL AMOUNT OF SUPPORT SERVICE NEEDED: $ Reminder: All expenses in this category must be documented with a receipt/invoice, log or quote before reimbursement. SUPPORTIVE SERVICE STATEMENT I hereby verify that the above information provided is true and accurate to the best of my knowledge. I agree to notify my WIA Case Manager of any changes that would alter my qualifications for support service funding. I understand that providing false information and/or misuse of these funds is punishable as a felony. I further understand and agree that all funds furnished for my support service needs shall be reimbursed on a pro-rated basis upon failure to complete the training program. Participant s Signature: I hereby verify by my signature, other options for supportive services have been examined and are not available through other community resources Case Manager s Name: Case Manager s Signature: PARTICIPANT NOTIFICATION/AGREEMENT OF FINAL AUTHORIZATION TOTAL AMOUNT AUTHORIZED: $ AUTHORIZED SIGNATURE: DATE: Bay Area WDB SUPPORTIVE SERVICES POLICY Page 12

14 Bay Area Workforce Development Board NON-WIA SUPPORT SERVICES SUPPORT EXPENSE FORM A-1 PARTICIPANT REQUEST/APPROVAL FUNDING SOURCE: Please select one JOB CENTER: Please select one PARTICIPANT S NAME: ADDRESS: CITY: STATE: ZIP: PHONE: ( ) PIN TYPE OF SUPPORT SERVICE NEEDED Items Needed (Specify) Cost Vendor $ $ $ $ TOTAL AMOUNT OF SUPPORT SERVICE NEEDED: $ Reminder: All expenses in this category must be documented with a receipt/invoice, log or quote before reimbursement. SUPPORTIVE SERVICE STATEMENT I hereby verify that the above information provided is true and accurate to the best of my knowledge. I agree to notify my WIA Case Manager of any changes that would alter my qualifications for support service funding. I understand that providing false information and/or misuse of these funds is punishable as a felony. I further understand and agree that all funds furnished for my support service needs shall be reimbursed on a pro-rated basis upon failure to complete the training program. Participant s Signature: I hereby verify by my signature, other options for supportive services have been examined and are not available through other community resources Case Manager s Name: Case Manager s Signature: PARTICIPANT NOTIFICATION/AGREEMENT OF FINAL AUTHORIZATION TOTAL AMOUNT AUTHORIZED: $ AUTHORIZED SIGNATURE: DATE: Bay Area WDB SUPPORTIVE SERVICES POLICY Page 13

15 Bay Area Workforce Development Board 317 West Walnut Street Green Bay, WI T (920) F (920) Form C Dear : SUBJECT: This letter is a request for information needed to comply with existing Federal Income Tax Laws. Please provide the information requested below and return this form to me. Federal Income Tax Law requires recipients of certain types of payments to provide a Taxpayer Identification Number (TIN) to payers. Failure to provide a TIN may result in the imposition of a $50 penalty by the Internal Revenue Service. In addition, payers may be required to withhold 20% of certain future payments (Backup Withholding). In order to avoid any penalties or backup withholding, we ask that you provide us with the information requested below (Categories 1 and 2 must be filled in to receive payment). 1. TAX IDENTIFICATION NUMBER (TIN) - OR - - Federal Taxpayer ID Number Social Security Number 2. TYPE OF ORGANIZATION Corporation Individual Other If other, are you certified? Yes No DO NOT or fax this completed form due to confidential information. Certification: Under penalties of perjury, I certify that the information provided above is true, correct and complete. Child Care Provider s Signature Date Sincerely, Debra LaViolette-Spevacek Controller Bay Area Workforce Development Board Bay Area WDB SUPPORTIVE SERVICES POLICY Page 14

16 Bay Area Workforce Development Board SUPPORT SERVICES FORM C-1 CHILDCARE AGREEMENT The Bay Area Workforce Development Board, Inc., herein after referred to as Bay Area WDB., hereby enters into agreement with Participant s Name: PIN: herein after referred to as Participant with childcare service for the dependent children: Name: Name: Name: Name: Children Receiving Childcare Services Birthdate: Birthdate: Birthdate: Birthdate: Estimated Time Frame for Services: From to Childcare Service to be Provide: Provider s Home Participant s Home Licensed Daycare Center The Bay Area WDB agrees to pay the childcare provider an allowance for the expressed purpose of adequate care for the dependent child(ren) while the Participant is reenrolled in a Program funded by WIA. 1. Participant shall: a. Acquire a responsible, adequate childcare provider over the age of 18. b. Be responsible for the submission in writing of any provider changes within 5 days of the change. c. Submit an Invoice (Form D) with all required signatures to the Bay Area W.D.B. based on class schedule. d. Be held responsible for childcare costs. e. Be held responsible for any childcare cost incurred for any period of time in which the participant is NOT attending the program activity. f. Immediately notify, in writing, the Case Manager of the termination of participation in the WIA program, the termination of the childcare need or any change in schedule. Failure to comply will result in discontinued funding. 2. Case Manager shall: a. Approve Childcare Provider selected by Participant. b. Determine the length of time childcare services will be provided and the amount of monthly payments based on a written schedule. c. Have the option of terminating childcare services when Participant or Provider fails to comply with this and/or any other agreement between the WIA Operator and the Participant and/or Provider. d. Notify the participant, in writing, of Participant s termination in the program, thus ending this agreement. It is further understood and agreed between the Bay Area WDB and the Participant that any portion of this agreement that may be in conflict with Workforce Investment Act regulations shall be null and void, and that this agreement can be terminated by any below signed party at any time, upon receipt of written notice. It is further understood and agreed that the Participant acknowledges the preceding agreement concerning the service to be provided for his/her dependent child(ren). Wherefore we enter into this agreement on Participant s Signature: Address: Bay Area WDB SUPPORTIVE SERVICES POLICY Page 15

17 Case Manager s Signature: Bay Area Workforce Development Board SUPPORT SERVICES FORM D CHILDCARE EXPENSE FORM Month: Name: Childcare Provider Mailing Address: City, State, Zip Phone Number: Licensed Other Childcare services were provided for the below individual s child / children (Circle One) for the month of and our bill was $ for the month. Childcare Provider s Signature Date Name: Address: Participant Participant s Signature Date Case Manager Job Center: Program: Adult Dislocated Other Youth In School Youth Out of School The above individual attended training classes for the month of Case Manager (please print) Date Case Manager s Signature Date Payment will be made to the CHILDCARE PROVIDER. It is the responsibility of the Case Manager to document the time, cost, and accuracy of the request and to verify the name and address of the provider. Bay Area WDB SUPPORTIVE SERVICES POLICY Page 16

18 STUDENT NAME CASE MANAGER Bay Area Workforce Development Board SUPPORT SERVICES FORM E STUDENT EXCEPTION REPORTING TRANSPORTATION CHILDCARE FALL WINTER SPRING SUMMER Whenever it is necessary to make modifications to the information provided WIA before the semester began this form must accompany any expense request and is to be approved by your Case Manager DATE CODE START TIME END TIME DESCRIPTION SIGNATURE VALIDATION CODES: LA Lab Attendance SIGNATURES IN Internship / Co-Op Student Case Manager Bay Area WDB SUPPORTIVE SERVICES POLICY Page 17

19 Bay Area Workforce Development Board WIA SUPPORT SERVICE TRANSPORTATION FORM F PARTICIPANT REQUEST/APPROVAL Funding Source: Please select one Job Center: Please select one Participant s Name: Address: City: State: Zip: Phone: ( ) PIN Starting From: To: Number of Miles, Round Trip: Semester Dates Needed: From: To: Days Per Week: Total Amount of Transportation Needed: $ NOT TO EXCEED MAXIMUM DAILY RATE SUPPORTIVE SERVICE STATEMENT I hereby verify that the above information provided is true and accurate to the best of my knowledge. I agree to notify my WIA Case Manager of any changes that would alter my qualifications for support service funding. I understand that providing false information and/or misuse of these funds is punishable as a felony. I further understand and agree that all funds furnished for my support service needs shall be reimbursed on a pro-rated basis upon failure to complete the training program. Participant s Signature: I hereby verify by my signature, the options for supportive services have been examined and are not available through other sources Case Manager s Name: Case Manager s Signature: PARTICIPANT NOTIFICATION OF FINAL AUTHORIZATION Total Amount Authorized: $ Authorized Signature: Please return this form to: Bay Area WDB SUPPORTIVE SERVICES POLICY Page 18

20 Bay Area Workforce Development Board WIA SUPPORT SERVICE TRANSPORTATION FORM G PARTICIPANT MILEAGE FORM FUNDING: Please select one JOB CENTER: Please select one NAME: ADDRESS: CITY: STATE: ZIP: Is this a new address since last month s form? Yes No PHONE: ( ) PIN This form is to be used for reimbursement of mileage costs incurred while you are involved in contracted activities. This form must be completed in ink. Use ONE form for each month. DATE PURPOSE OF TRAVEL FROM TO ROUND TRIP MILES I declare that this account of daily mileage traveled is true under penalty of perjury. I understand that my mileage will be verified by the checking of my monthly attendance records. Mileage reimbursement will be mailed to me after all forms have been submitted, verified and processed. PARTICIPANT S SIGNATURE: DATE: Training Attendance Signature (Verification of above information) CASE MANAGER S SIGNATURE: DATE: Bay Area WDB SUPPORTIVE SERVICES POLICY Page 19

21 Bay Area Workforce Development Board WIA SUPPORT SERVICES TRANSPORTATION FORM H GAS CARD PARTICIPANT MILEAGE FORM Funding Source: Please select one Job Center: Please select one Participant s Name: Address: City: State: Zip: Phone: ( ) PIN: Starting From: To: Round Trip Miles: Number of Trips: Service Dates Needed: From: To: Total Request: $ Vendor Name: Vendor Address: Vendor City: State: Zip: Reason for needing gas card SUPPORTIVE SERVICE STATEMENT I hereby verify that the above information provided is true and accurate to the best of my knowledge. I agree to notify my WIA Case Manager of any changes that would alter my qualification for support service funding. I understand that providing false information and/or misuse of these funds is punishable as a felony. Participant s Signature: I hereby verify by my signature, other options for supportive services have been examined and are not available through other community resources Case Manager s Name: Case Manager s Signature: PARTICIPANT NOTIFICATION OF FINAL AUTHORIZATION Total Amount Authorized: $ Authorized Signature: Bay Area WDB SUPPORTIVE SERVICES POLICY Page 20

22 Bay Area Workforce Development Board WIA SUPPORT SERVICES REIMBURSEMENT FORM I WIA DIRECT REIMBURSEMENT FUNDING SOURCE: Please select one JOB CENTER: Please select one PARTICIPANT S NAME: ADDRESS: CITY: STATE: ZIP: PIN # Training Support REIMBURSEMENT NEEDS (do not include sales tax) Items Needed (Specify) Cost Approved TOTAL REQUEST $ $ $ $ $ $ $ $ $ Reminder: All expenses in this category must be documented with a receipt/invoice before reimbursement. Tuition, books, and/or testing fees will require final grade submission along with request. CERTIFICATIONS I hereby verify that the above information provided is true and accurate to the best of my knowledge. I agree to notify my WIA Case Manager of any changes that would alter my qualifications for support service funding. I understand that providing false information and/or misuse of these funds is punishable as a felony. Participant s Signature: I hereby verify by my signature, other options for supportive services have been examined and are not available through other community resources Case Manager s Name: Case Manager s Signature: PARTICIPANT NOTIFICATION OF FINAL AUTHORIZATION Total Amount Authorized: $ Authorized Signature: Bay Area WDB SUPPORTIVE SERVICES POLICY Page 21

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