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West Virginia Income Maintenance Manual Chapter 18

West Virginia Income Maintenance Manual Page 182 Chapter 18 WV WORKS Activities/Requirements

APPENDIX C: INSTRUCTIONS FOR COMPLETING DFA-EIP-1 An DFA-EIP-1 must be completed for each individual placed into the Employer Incentive Program (EIP). Group contracts are not acceptable. In addition, all agreements must be negotiated and signed by all parties prior to the initial start date. Payment to the employer will be based on the hours of work shown on the appropriate time sheet. Section I WV DOHS Office Address: Local DOHS Office address and telephone number Agreement Number: Authorized Representative: Person authorized by employer to sign EIP Agreement The agreement number shows agreement, the State Fiscal Year, the county number and the sequential agreement number for that county Agreement Number Example: EIP-06-01-05 is for Fiscal Year 2006 (06), Barbour County (01), sequential EIP Agreement number 5 (05) Participant Name: Name of person being assigned Social Security Number (SSN): Participant’s SSN PIN: Participant’s PIN Section II Employer: Names of Employer Address: Address where reimbursement is to be mailed and phone number. Vendor Number: Assigned by fiscal office FEIN: Federal Employer TAX Identification Number Worker’s Comp Number: Employer’s Worker’s Compensation Number