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• <br />0 <br />0 <br />SUPPORT SERVICES REQUEST FORM <br />SECTION 1" GENERAL <br />PARTICIPANT,IIVf,ORM1T,lON. <br />Participant Name: <br />Date: <br />WIA Application #: <br />Telephone: ( ) <br />WIA CaIGRIP <br />❑ OCAPICA <br />❑ CORE <br />Grant Code: <br />Location/Center: <br />El Bishop Manor <br />❑Buena Clinton <br />❑ Westminster HS <br />❑Other: <br />ISY OSY <br />❑ 266 ❑ 257 ❑ 260 <br />❑ Community Day <br />"SECTION111 =PARTICIPANT S STATEIVfENT°OFgNEED <br />I <br />Payable to: Amount: $ <br />SECTION III.'5UPsPORT�VtSs' VICES,_REQU,ES_T`&OUTCOME <br />REPORT, <br />Supportive Services and <br />Amount Requested <br />Supportive Service <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 />❑ Copy of Gas Card <br />$ <br />❑ Copy Bus Pass <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 />❑ Copy of Gas Card <br />$ <br />❑ Copy Bus Pass <br />A t $ "f <br />liSECTION IV ACKNOWLEDGEMENT;OF�.RECEIPTREQUES[ED � ? <br />I understand that I am required to return proper receipts and/or documentation that is requested for the purchases and <br />services that I have received from the Supportive Services Provider. I understand that if the required receipts and/or <br />documentation in the amount and by the due date detailed above are not returned there will be no additional supportive <br />services provided to me. <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 />Participa nt Signatu re Date <br />Case Manager Signature Date Program Manager Signature Date <br />Program Director Signature (over $500) <br />Finance Director Signature Date <br />EXHIBIT A <br />