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00o DSHS <br />Contractor <br />Signature <br />AFP Number <br />Division of Vocational Rehabilitation (DVR) <br />Exhibit E: <br />School -to -Work Billing Checklist <br />Month and Year <br />Date of Signature <br />Student Initials <br />To be filled out by DVR Staff Only: <br />Activity Billed <br />Amount <br />DVR staff sign and date below to confirm <br />Billed <br />items received and to authorize payment <br />❑ <br />Intake Meeting <br />$ <br />2,000 <br />❑ <br />Assessment <br />$ <br />3,000 <br />❑ <br />Job Seeker Tools <br />$ <br />1,000 <br />❑ Job Offer <br />$ <br />2,000 <br />❑ <br />Employment Verification <br />$ <br />1,000 <br />$ <br />5,000 <br />❑ Stabilization <br />Total Billing: <br />$ <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 />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 />Any questions, please contact the School -to -Work Team at <br />DVRSchoolioWork dshs.wa. ov. <br />Exhibit E: School -to -Work Billing Checklist <br />DSHS 11-195A (04/2026) <br />