HHSA - DSS - WTW Activity Attendance Verification

WTW ACTIVITY ATTENDANCE VERIFICATION
Nevada County Social Services
988 McCourtney Rd.
Grass Valley, Ca. 95949
Case Name
Case Number
Worker Name*
Worker Telephone
In order to receive supportive services for transportation and/or child care, we need you to provide information about your Welfare-to-Work activity attendance.

Please be sure to submit verification of reported hours. This can be signed documents from your provider/supervisor, time cards, or pay stubs.
Submit This Report to Your Worker by
WTW Activity
WTW Activity Site Location
Report Month/Year
WEEK 1:
Dates From

MonthDayYear
To

MonthDayYear
Enter the NUMBER of hours completed
Mon
Tue
Wed
Thu
Fri
Sat
Sun
Total
WEEK 2:
Dates From

MonthDayYear
To

MonthDayYear
Enter the NUMBER of hours completed
Mon
Tue
Wed
Thu
Fri
Sat
Sun
Total
WEEK 3:
Dates From

MonthDayYear
To

MonthDayYear
Enter the NUMBER of hours completed
Mon
Tue
Wed
Thu
Fri
Sat
Sun
Total
WEEK 4:
Dates From

MonthDayYear
To

MonthDayYear
Enter the NUMBER of hours completed
Mon
Tue
Wed
Thu
Fri
Sat
Sun
Total
WEEK 5:
Dates From

MonthDayYear
To

MonthDayYear
Enter the NUMBER of hours completed
Mon
Tue
Wed
Thu
Fri
Sat
Sun
Total
Monthly Hours

Did you miss any days in the month?

YESNO
If you are absent for more than 3 days, provide documentation for absence to your ECM.
Date Missed

MonthDayYear
Reason
Other Reason
Date Missed

MonthDayYear
Reason
Other Reason
Date Missed

MonthDayYear
Reason
Other Reason
Contact your Employment Case Manager to report any changes in your activity.
Activity Attendance Verified by:
Name/Title
Signature
Date

MonthDayYear
Phone No.
Submit verification documents here

Cancelof
CERTIFICATION - I certify under penalty of perjury that the information provided on this form is true and correct.
Participant signature*
Date*

MonthDayYear
Activity Attendance Verified by:
Should be Empty:

WEEK 1: