Work-Based Learning Income Verification Form

Work-Based Learning Income Verification Form

The incomes of Individuals who participate in RISE subsidized work based learning (WBL) activities are excluded in their Basic Food Assistance Unit (BFAU). Please update the Basic Food AU as follows:

RISE Participant name: Click here to enter text.

Client Id number/eJAS ID/SSN: Click here to enter text.

Job Title: Click here to enter text.

Employer: Click here to enter text.

Employer Address: Click here to enter text.

Employer phone number: Click here to enter text.

Start Date: Click here to enter text.

Hourly wage: Click here to enter text.

Hours per week: Click here to enter text.

Payday schedule: ☐ Weekly

☐ Bi-weekly

☐ Monthly

This verification of excluded income, completed on Click here to enter a date. by:

RISE Agency: Click here to enter text.

RISE Case Manager: Click here to enter text.

DSHS Staff Only:

See the Treatment of Income chart in the Eligibility A-Z Manual (E-Z) for further clarification.

This form was created and approved by Office of Program and Food Policy. If you have any questions or concerns please contact or Shavana Howard at 360-725-4338.