Free Form VR-44S: Supplemental Billing Request - Nebraska

VR-44S(4/09) SUPPLEMENTAL BILLING REQUEST Complete in accordance with Instructions for Completing Billing Information on the Vocational Rehabilitation Plan form when additional funds are needed to complete an existing plan. If there are changes to the Type of Plan, Training/Vocational Goal, or length of the plan another Vocational Rehabilitation Plan must be submitted. Employee Name: Reason for Request: Date of Request:

A. TUITION & FEES:

$___________________

Start Date:

End Date:

Authorize to:________________________________________________________________________________________________ Address: _________________________________________________________________________________________________ City: ________________________________________State: ____________ ZIP: _________________ B. REQUIRED BOOKS: $ __________________ Start Date: End Date:

Authorize to: _________________________________________________________________________________________________ Address: __________________________________________________________________________________________________ City: _______________________________________ State: _____________ZIP: _________________ C. GENERAL SUPPLIES: $ __________________ Start Date: End Date:

Authorize to: _______________________________________________________________________________________________ Address: ________________________________________________________________________________________________ City: _______________________________________ State: _____________ZIP: _________________ D. REQUIRED SUPPLIES: $ __________________ Start Date: End Date:

Authorize to: _______________________________________________________________________________________________ Address: ________________________________________________________________________________________________ City: ______________________________________ State: ____________ E. SPECIAL FEES: $ __________________ Start Date: ZIP: ___________________ End Date:

_______________________________________________________________________________________________________ Authorize to:______________________________________________________________________________________________ Address: _______________________________________________________________________________________________ City: ______________________________________ F. TUTOR INFORMATION & FEES: State: ____________ Start Date: ZIP: __________________ End Date:_______________ = Total: $_____________________

Hourly Rate: $____________ x Hours Per Week: ___________ x Number of Weeks:

Authorize to: __________________________________________________ SSN/FEIN:_____________________ Address: ________________________________________________________________________________________________ City: _____________________________________ State: ______________ ZIP: ______________________________

Requested by:
Vocational Rehabilitation Counselor/ Certification #

Approved by:
WCC Vocational Rehabilitation Specialist

Date: