Free 47194.pdf - Indiana

SELF-SUFFICIENCY PLAN FOR IMPACT CLIENT
State Form 47194 (R4 / 4-09) / IMP 0007
Date of next review (month, day, year) Name of client Name of IMPACT case manager Social Security number Telephone number Date (month, day, year) Case number

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(
Employment goal: Personal goal:

)

Strengths:

Barriers:

Activity

Referral to or Responsibility for

Purpose

Assignment Date
(month, day, year)

Completion Date
(month, day, year)

Participation Hours

By signing this plan for employment, I agree to the goals, strengths, barriers, and activities listed above. I also agree that I will seek and retain employment. I understand that if I need support services such as childcare, clothing, transportation expenses, or vehicle expenses, I should contact the IMPACT Case Manager. I understand my rights and responsibilities under the IMPACT Program. I understand conciliation procedure should I disagree with this plan. I understand compliance with this plan and the penalties for not participating in the program.
Signature of client Date (month, day, year) Signature of IMPACT staff Date (month, day, year)