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• <br />• <br />INCENTIVE REQUEST FORM <br />SECTION I GENERAL <br />PARTICIPANT INFORMAT'',[ON; <br />tt. <br />Participant Name: <br />Date: <br />WIA Application #: <br />Telephone: ( ) <br />Grant Code: <br />WIA <br />CaIGRIP <br />1 <br />Location/Center: <br />❑ OCAPICA <br />❑ Bishop Manor <br />❑ Buena Clinton <br />❑ Community Day <br />❑ CORE <br />❑ Westminster HS <br />❑ Other: <br />ISY OSY <br />❑ 256 ❑ 2S7 <br />❑ 260 <br />Payable to: <br />Y <br />Amount: $ <br />,SECTION III: INCENTNE SERVICES REQUES'( &;OUTCOME'REPORT, v,�`r�`�„,�„, �' <br />„��'}""�t``,�,'„ryz ' t � },M <br />Incentive and Amount <br />Requested <br />Incentive <br />Outcome <br />Amount/Check # <br />Type of Receipt and Due Date <br />Name of Vendor: <br />Amount Requested: <br />❑ Provided Service <br />❑ Service Denied <br />Amount: $ <br />Check #: <br />❑ Yes <br />❑ No, Due Date <br />❑ Copy of Receipt <br />Name of Vendor: <br />Amount Requested: <br />$ <br />❑ Provided Service <br />❑ Service Denied <br />Amount: $ <br />Check #: <br />❑ Yes <br />❑ No, Due Date <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 />L Finance Director Signature Date <br />EXHIBIT A <br />