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INCENTIVE REQUEST FORM <br />SEC�TIOIV I`4�GI_N1 E AGPARTi�CIP�4NF�1N€ORl <br />lA7J��i�l ' �� <br />-M <br />-.M � `�� <br />- �� t<_, <br />Participant Name: <br />Date: <br />WIA Application #: <br />Telephone: ( ) <br />WIA <br />CaIGRIP <br />❑ OCAPICA <br />❑ CORE <br />SY OSY <br />❑ Bishop Manor <br />❑ Westminster HS <br />Grant Code: <br />❑ 256 ❑ 257 <br />❑ 260 <br />Location /Center: <br />❑ Buena Clinton <br />❑ Other: <br />❑ Community Day <br />''EIVTI E i fi M C4R C0N7x ENxONC r s <br />WIR. _ <br />I <br />Payable to:7 Amount: $ <br />SE�CTJON71t' 1�110ENTj1fS1µRVlCESEtQUESTx AE3U,0' <br />µIncentive <br />and Amount <br />Incentive <br />Requested <br />Outcome <br />Amount /Check # <br />Type of Receipt and Due Date <br />Name of Vendor: <br />❑ Yes <br />❑ Provided Service <br />Amount: $ <br />❑ No, Due Date <br />❑ Service Denied <br />Check #: <br />❑ Copy of Receipt <br />Amount Requested: <br />Name of Vendor: <br />❑ Yes <br />❑ Provided Service <br />Amount: $ <br />❑ No, Due Date <br />❑ Service Denied <br />Check #: <br />Amount Requested: <br />I understand that the above mentioned services provided by OCAPICA are solely for my immediate families' (immediate family <br />includes children and spouse) and my use. If I use the services provided for any other activity or give to any person, other <br />than my immediate family, I would be committing fraud that may be subject to consequence. OCAPCIA does not accept any <br />type of payment from Participants for share of cost. <br />Participant Signature Date <br />Case Manager Signature Date Program Manager Signature Date <br />Program Director Signature (over $500) <br />Finance Director Signature Date <br />