DSHS Form 11-071 "Dvr Employer Expense Worksheet (Division of Vocational Rehabilitation)" - Washington

What Is DSHS Form 11-071?

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 September 1, 2007;
  • The latest edition provided by the Washington State Department of Social and Health Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a printable version of DSHS Form 11-071 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 11-071 "Dvr Employer Expense Worksheet (Division of Vocational Rehabilitation)" - Washington

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STATE OF WASHINGTON
DEPARTMENT OF SOCIAL AND HEALTH SERVICES
DIVISION OF V OCATIONAL REHABILITATION
Customer Internship Program
Employer Expense Worksheet
INTERN’S NAME
INTERNSHIP BEGIN DATE
END DATE
NUMBER OF EXPECTED
NUMBER OF PAY PERIODS
WORK HOURS PER PAY
HOURLY WAGE
TOTAL EXTIMATED WAGES
IN INTERNSHIP PERIOD
PERIOD
X
X
$
Total estimated wages (from above)
$
Total estimated payroll expenses (taxes, workers compensation)
$
Other expense (describe):
$
Other expense (describe):
$
Other expense (describe):
$
Total employer expenses
$
EMPLOYER’S SIGNATURE
DATE
TELEPHONE NUMBER
EMPLOYER EXPENSE WORKSHEET
DSHS 11-071 (09/2007)
STATE OF WASHINGTON
DEPARTMENT OF SOCIAL AND HEALTH SERVICES
DIVISION OF V OCATIONAL REHABILITATION
Customer Internship Program
Employer Expense Worksheet
INTERN’S NAME
INTERNSHIP BEGIN DATE
END DATE
NUMBER OF EXPECTED
NUMBER OF PAY PERIODS
WORK HOURS PER PAY
HOURLY WAGE
TOTAL EXTIMATED WAGES
IN INTERNSHIP PERIOD
PERIOD
X
X
$
Total estimated wages (from above)
$
Total estimated payroll expenses (taxes, workers compensation)
$
Other expense (describe):
$
Other expense (describe):
$
Other expense (describe):
$
Total employer expenses
$
EMPLOYER’S SIGNATURE
DATE
TELEPHONE NUMBER
EMPLOYER EXPENSE WORKSHEET
DSHS 11-071 (09/2007)