Free Monthly Tutor Payment Form - Nebraska

R(04/09)

Nebraska Workers' Compensation Court MONTHLY TUTOR PAYMENT FORM

Tutor Name: Address:
(Street Address)

Social Security#:
(Required for payment)

(City)

(State)

(Zip)

Phone: Dates, Hours, and Type of Instruction:
DATE
MM/DD/YYYY

Employee:

GROUP
TIME IN/OUT TOTAL # HOURS

INDIVIDUAL
TIME IN/OUT TOTAL # HOURS

I certify that this information is correct to the best of my knowledge.

Tutor Signature

Date

Vocational Rehabilitation Counselor Signature

Date

For Court Use Only Hourly Rate Group Individual Hours Per Month Group Individual $ $

Total Amount to be Paid to Tutor $

Total

Total Court Vocational Rehabilitation Specialist Signature Date