Plan Time Cost Travel Encumbrance {F245-454-000}

Department of Labor and Industries Claims Section PO Box 44269 Olympia WA 98504-4269 Time Encumbrance Form Modified Early Termination Original Revised This form contains auto-calculations Date Modification(s) Time Frames Plan Information Goal Worker Name Claim # Training Site Cost Other (specify) Start Date End Date Early Termination Date LEP Start Date O'NET DOT# Method Formal OJT Combined LEP End Date Start Dates (mm/dd/yyyy) End Dates (mm/dd/yyyy) Plan length (# calendar days) Name of Training Provider(s) 1. 2. 3. 4. Total Vocational Provider Assigned VRC Name Firm Provider # VRC Phone # Department Use Only VSS Signature Approved VSS Comments Branch # 0 Signature VRC # VRC Fax # Date Not Approved F245-376-000 Time Encumbrance Form 07-2015 American LegalNet, Inc. www.FormsWorkFlow.com Index: VPLAN