Form Dss-2625 - Food And Nutrition Services E&t Information Transmittal

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FOOD AND NUTRITION SERVICES E&T INFORMATION TRANSMITTAL
______________________
____________________ __
_______________
___________________
Last Name
First Name
MI
FNS Case #
Social Security #
_________________________________________________________
_______________
 M
F
Address
DOB
________________________________________________________
___________________
Address
Telephone #
A. PLACEMENT
The above referenced FNS E&T program participant:
 W as placed by ESC with _______________________________ as ______________________________
 Obtained employment with ____________________________ as _______________________________
 Enrolled in Education and Training with _________________ for _______________________________
B. REQUEST FOR REFERRAL
On this date ____________________, the above referenced individual stated that he/she is included in an active FNS case
and requested to volunteer for participation in the E&T program.
C. REQUEST FOR TERMINATION OF VOLUNTEER STATUS
 By Volunteer
 By ESC - The above referenced FNS E&T program participant failed to report for the following services:
 Assessment
 Job Interview
 4 or 8 week Job Search Follow-up Interview
 Counseling
 Testing
 ESC Call-in
 E ducation/Training Application Process
 Work
D. FOR DSS OFFICE USE ONLY:
 Request Cure of CAREER Start Disqualification by attending ESC assessment only
 Request Cure of E&T Disqualification for failure to attend ESC assessment
 Request Cure of E&T Disqualification for failure to complete job search
_________________________________________
Caseworker Signature
Date
E. DISQUALIFICATION PROCESS
The above referenced FNS E&T program participant:
 D id not comply with the E&T or CS requirements that caused disqualification.
 Complied with the E&T or CS requirements that caused disqualification.
 C omplied with the E&T or CS requirements that caused disqualification and wishes to participate as a volunteer.
____________________________________
____________________________
__________________
ESC Consultant
ESC Office
Date
DSS-2625 (Rev. 11/10)
NCESC-2625 (Rev. 11/10)

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