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<br />Division of Vocational Rehabilitation <br />Exhibit F: <br />School-to-Work Billing Checklist <br />Sections to be filled <br />out by Contractor <br />Sections to be filled <br />out by DVR <br />Contractor <br /> <br />Month and Year <br /> <br />Signature Date of Signature <br /> <br />AFP Number <br /> <br />Student Initials <br /> <br />Activity Billed Amount <br />Billed <br />DVR Staff Verification (Sign and Date) to confirm <br />items received and payment authorization <br /> Intake Meeting $ 3,000 <br /> Assessment $ 2,000 <br /> Job Seeker Tools $ 1,000 <br /> Job Offer $ 2,000 <br /> Employment Verification $ 1,000 <br /> Stabilization $ 5,000 <br />Total Billing: $ <br />Instructions: <br />1. The Student Guide is sent monthly to the Student’s Team, including the DVR Counselor . <br />2. The Contractor checks the appropriate box(es) as the corresponding activities are completed in <br />the Student Guide (one form per student). <br />3. The Contractor submits this completed form to the assigned DVR Counselor. <br />4. The DVR Counselor confirms information from monthly submissions of the Student Guide, <br />verifies activities were completed, then signs and dates the checklist. <br />5. The DVR Counselor submits for payment. <br /> <br />Notables: <br />• The Student Guide serves as documentation for proof of completion for the payment/activity <br />point. <br />• The Contractor submits no less than three (3) separate checklists to the assigned DVR <br />Counselor for each student (Submitting all payment points separately is also an option). <br /> <br />Any questions, please contact the School-to-Work Team at <br />DVRSchoolToWork@dshs.wa.gov. <br /> <br />Exhibit F: School-to-Work Billing Checklist <br />DSHS 11-195 (05/2025)