DSHS Form 07-103 "Basic Food Employment and Training (Bfet) Participant Reimbursement" - Washington

What Is DSHS Form 07-103?

This is a legal form that was released by the Washington State Department of Social and Health Services - a government authority operating within Washington. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2020;
  • The latest edition provided by the Washington State Department of Social and Health Services;
  • Easy to use and ready to print;
  • Available in Spanish;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of DSHS Form 07-103 by clicking the link below or browse more documents and templates provided by the Washington State Department of Social and Health Services.

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Download DSHS Form 07-103 "Basic Food Employment and Training (Bfet) Participant Reimbursement" - Washington

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CLIENT’S PRINTED NAME
BASIC FOOD EMPLOYMENT AND TRAINING (BFET)
Participant Reimbursement
CLIENT’S EJAS ID
DATE
Organization Staff Portion
CHECK THE TYPE(S) OF REIMBURSEMENT(S)
ENTER AMOUNT
$
Transportation: Bus pass / ticket - How many:
daily /
weekly /
monthly
Bus pass / ticket identifying number(s):
$
Transportation: Fuel card(s) - Card number:
$
Transportation: ORCA Card / ORCA Refill - Card number:
$
Transportation: Other (Explanation required)
$
Clothing (e.g., interview clothes, shoes, boots, uniforms)
$
Child Care (e.g., CCSP copay or non-CCSP)
Medical
$
Educational / Credential Testing (e.g., high school equivalency test, literacy level test, aptitude
$
testing, CNA test, short-term contracted training)
$
Personal Hygiene and Grooming (e.g., toothpaste, shampoo, haircut)
$
Books, tools, and training supplies
$
Housing
$
Internet service / cell phone and minutes
$
Digital support (tablet, laptop, accessories)
Other: (Explanation required)
$
OPTIONAL: Check below if a gift card or similar payment type was issued.
Client was given a “Gift Card Receipt Attachment” and a prepaid envelope to return receipt(s) for all purchase.
MANDATORY: Enter justification for each type of reimbursement given (i.e., reason needed and other details such as:
non-CCSP child care due to temporary ineligibility, for interview pants, mandatory training uniform, shirt,
shoes, books, etc.):
AUTHORIZED PROGRAM APPROVAL PRINTED NAME
AUTHORIZED PROGRAM APPROVAL SIGNATURE
DATE
Client Declaration and Signature
I understand and agree that:
• I received the above issuance(s).
• I have not received the same type of assistance in the current month from any other organization including but not
limited to: other BFET organizations, WorkFirst, LEP Pathways, etc.
• I can only use the assistance provided (including gift cards) for work or training related purposes as described above.
• Selling or misusing the benefit may result in BFET disqualification and I would have to pay back the funds.
• I will return the receipt(s) for all fuel and gift card purchases if I received a “Gift Card Receipt Attachment.”
CLIENT’S PRINTED NAME
CLIENT’S SIGNATURE
DATE
BASIC FOOD EMPLOYMENT AND TRAINING (BFET) PARTICIPANT REIMBURSEMENT
DSHS 07-103 (REV. 10/2021)
CLIENT’S PRINTED NAME
BASIC FOOD EMPLOYMENT AND TRAINING (BFET)
Participant Reimbursement
CLIENT’S EJAS ID
DATE
Organization Staff Portion
CHECK THE TYPE(S) OF REIMBURSEMENT(S)
ENTER AMOUNT
$
Transportation: Bus pass / ticket - How many:
daily /
weekly /
monthly
Bus pass / ticket identifying number(s):
$
Transportation: Fuel card(s) - Card number:
$
Transportation: ORCA Card / ORCA Refill - Card number:
$
Transportation: Other (Explanation required)
$
Clothing (e.g., interview clothes, shoes, boots, uniforms)
$
Child Care (e.g., CCSP copay or non-CCSP)
Medical
$
Educational / Credential Testing (e.g., high school equivalency test, literacy level test, aptitude
$
testing, CNA test, short-term contracted training)
$
Personal Hygiene and Grooming (e.g., toothpaste, shampoo, haircut)
$
Books, tools, and training supplies
$
Housing
$
Internet service / cell phone and minutes
$
Digital support (tablet, laptop, accessories)
Other: (Explanation required)
$
OPTIONAL: Check below if a gift card or similar payment type was issued.
Client was given a “Gift Card Receipt Attachment” and a prepaid envelope to return receipt(s) for all purchase.
MANDATORY: Enter justification for each type of reimbursement given (i.e., reason needed and other details such as:
non-CCSP child care due to temporary ineligibility, for interview pants, mandatory training uniform, shirt,
shoes, books, etc.):
AUTHORIZED PROGRAM APPROVAL PRINTED NAME
AUTHORIZED PROGRAM APPROVAL SIGNATURE
DATE
Client Declaration and Signature
I understand and agree that:
• I received the above issuance(s).
• I have not received the same type of assistance in the current month from any other organization including but not
limited to: other BFET organizations, WorkFirst, LEP Pathways, etc.
• I can only use the assistance provided (including gift cards) for work or training related purposes as described above.
• Selling or misusing the benefit may result in BFET disqualification and I would have to pay back the funds.
• I will return the receipt(s) for all fuel and gift card purchases if I received a “Gift Card Receipt Attachment.”
CLIENT’S PRINTED NAME
CLIENT’S SIGNATURE
DATE
BASIC FOOD EMPLOYMENT AND TRAINING (BFET) PARTICIPANT REIMBURSEMENT
DSHS 07-103 (REV. 10/2021)