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Nma;-u* <br />Division of Vocational Rehabilitation (DVR) <br />Exhibit E: <br />School-to-Work Billing Ghecklist <br />Contractor Month and Year <br />Signature Date of Signature <br />AFP Number Student lnitials <br />Activity Billed Amount <br />Billed <br />To be filled out by DVR Staff OnlY: <br />DVR staff sign and date below to confirm <br />items received and to authorize payment <br />! tntake Meeting $2 000 <br />n Assessment $3 000 <br />I loO Seeker Tools $1 000 <br />E ton offer $2 000 <br />I Employment Verification $1 000 <br />! Stabilization $5 000 <br />Total Billing $ <br />lnstructions: <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 />DVRSchoolToWo rk@dshs.wa.oov. <br />Exhibit E: Schoolto-Work Billing Checklist <br />DSHS 11-195A (O4t2026)