Wtw 2 - Welfare To Work Plan Activity Assignment Page 3
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4SUPPORTIVE SERVICES
The county must give me supportive services (child care; transportation; and work, education and training related expenses)
if I need them to participate in my mandatory or voluntary Welfare-to-Work assignments and Welfare-to-Work rules allow for
them.
■ ■
My county worker has reviewed my need for Welfare-to-Work supportive services for each activity listed in my plan. I
understand that I do not have to do my assignment until the supportive services I need have been arranged.
■ ■
I understand that I must tell my Welfare-to-Work worker right away if my need for Welfare-to-Work supportive services
changes, or if I no longer need them. If I do not report the changes in advance, the county may not be able to pay
for them.
■ ■
I understand that if the county pays for supportive services that are more than what I needed to participate in
Welfare-to-Work, I will have to pay the county back.
I need the following supportive services:
■ ■
Child Care
■ ■
I do not need the county to pay for child care at this time, but I have the right to request child care later.
________________ (initial and date)
■ ■
Transportation:
■ ■
■ ■
■ ■
Bus Pass
Mileage
Parking
■ ■
Other (toll fees, taxis, etc.) : ____________________________________________________________________
■ ■
I need advanced payment for transportation.
■ ■
I do not need the county to pay for transportation at this time, but I have the right to request transportation later.
________________ (initial and date)
■ ■
Ancillary (other, such as books, tools, uniforms, etc.) costs for:
1. _________________________________
2. _________________________________
3. _________________________________
4. _________________________________
■ ■
I need advanced payment for ancillary costs.
■ ■
I do not need the county to pay for ancillary costs at this time, but I have the right to request ancillary costs later.
________________ (initial and date)
■ ■
In order to successfully participate in the assigned activities I need the following accommodations (help): Please
specify - for example: special services because of a disability (reading me notices, large print, special supplies, etc.) .
1. _________________________________
2. _________________________________
3. _________________________________
4. _________________________________
WTW 2 (12/12) REQUIRED FORM - SUBSTITUTES PERMITTED
PAGE 3 OF 4
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