25D - AGMT - WIA YOUTH PROGRAM FUND 13-14

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SUPPORT SERVICES REQUEST FORM ;nSCONlGItka�� C1 PANT,IiVFQR1Fla Participant Name: Date: WIA Application #: Telephone: ( ) WIA CaIGRIP ❑ OCAPICA ❑ CORE E] Bishop Manor ❑ Westminster HS ISY OSY Grant Code: ❑ 256 ❑ 257 ❑ 260 Location /Center: ❑ Buena Clinton ❑ Other: ❑ Community Day Payable to: Amount: $ Supportive Services and Supportive Service Amount /Check # Type of Receipt and Due Date Amount Requested Outcome Name of Vendor: ❑ Yes ❑ Provided Service Amount: $ ❑ No, Due Date ❑ Service Denied Check #: ❑ Copy of Receipt Amount Requested: ❑ Copy of Gas Card $ ❑ Copy Bus Pass Name of Vendor: ❑ Yes ❑ Provided Service Amount: $ ❑ No, Due Date ❑ Service Denied Check #: ❑ Copy of Receipt Amount Requested: ❑ Copy of Gas Card $ ❑ Copy Bus Pass I understand that I am required to return proper receipts and /or documentation that is requested for the purchases and services that I have received from the Supportive Services Provider. I understand that if the required receipts and /or documentation in the amount and by the due date detailed above are not returned there will he no additional supportive services provided to me. I understand that the above mentioned services provided by OCAPICA are solely for my immediate families' (immediate family includes children and spouse) and my use. If I use the services provided for any other activity or give to any person, other than my immediate family, I would be committing fraud that may be subject to consequence. CCAPCIA does not accept any type of payment from Participants for share of cost. Participant Signature Date Case Manager Signature Date Program Manager Signature Date Program Director Signature (over $500) Finance Director Signature Date W_: 1