• WTW ACTIVITY ATTENDANCE VERIFICATION

  • Format: (000) 000-0000.

  • 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.

  • WEEK 1:

  • Dates From
     / /
  • To
     / /

  • Enter the NUMBER of hours completed

  • WEEK 2:

  • Dates From
     / /
  • To
     / /

  • Enter the NUMBER of hours completed

  • WEEK 3:

  • Dates From
     / /
  • To
     / /

  • Enter the NUMBER of hours completed

  • WEEK 4:

  • Dates From
     / /
  • To
     / /

  • Enter the NUMBER of hours completed

  • WEEK 5:

  • Dates From
     / /
  • To
     / /

  • Enter the NUMBER of hours completed

  • Did you miss any days in the month?

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

  • Date Missed
     / /
  • Date Missed
     / /
  • Date Missed
     / /

  • Contact your Employment Case Manager to report any changes in your activity.

  • Activity Attendance Verified by:

  • Date
     / /
  • Format: (000) 000-0000.
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • CERTIFICATION - I certify under penalty of perjury that the information provided on this form is true and correct.

  • *   

  • Date*
     / /

  • Activity Attendance Verified by:

  •   
  • Should be Empty: