In this tutorial, we will be walking you through the steps of how to fill out Form F245 346 000. This form is used to declare an abandonment of a Mexican national's permanent residence. It is important that you complete this form accurately and submit it to the appropriate authorities, as it is a legal document. We will be providing specific instructions on how to fill out each section of the form, so that you can ensure that your declaration is accurate. Let's get started!
Question | Answer |
---|---|
Form Name | Form F245 346 000 |
Form Length | 3 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 45 sec |
Other names | of 346 fillable form, p3, F245030-000, affixed |
Mail completed application form to:
Department of Labor & Industries
Claims Section
PO Box 44291
Olympia WA
JOB MODIFICATION ASSISTANCE APPLICATION
|
One vendor per application form |
|
Date of injury |
|
|
Claim number |
||||||||
|
|
|
|
|
|
|
|
|
|
|||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Injured worker’s name |
|
|
|
|
|
|
Accepted diagnosis |
|
|
|
|
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
Vocational counselor/job modification consultant |
|
|
|
|
|
|
|
|
|
Provider number |
||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Firm’s name |
|
|
|
|
|
|
|
|
|
|
|
Phone number |
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Address |
|
|
|
|
|
|
|
|
|
|
|
Fax number |
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
City |
|
|
|
|
|
|
|
State |
|
|
ZIP+4 |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Worker’s Job title |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Employer name |
|
|
|
|
|
|
|
|
|
|
|
Phone number |
||
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|||
RESTRICTIONS |
|
|
DESCRIPTION OF JOB MODIFICATION |
|
|
|
|
|
||||||
|
|
|
|
|
|
|
|
|
|
|||||
|
|
|
|
|
|
|
|
|
|
|||||
ITEMIZATION OF COSTS: |
|
|
|
|
|
REQUIRED |
|
Labor and Industries (L&I) provider |
||||||
|
|
|
|
|
|
DOCUMENTATION |
|
number required for payment. |
||||||
Equipment |
|
|
|
|
|
Job modification narrative |
|
If equipment vendor does not have a |
||||||
|
|
|
|
|
|
|
||||||||
|
|
|
|
|
|
|
L&I provider number – Call: |
|||||||
|
|
|
|
|
|
or consultation report |
|
|||||||
Tools |
|
|
|
|
|
|
Provider Accounts |
|||||||
|
|
|
|
|
|
|
|
|
||||||
|
|
|
|
|
|
|
AND |
|
(360) |
|
||||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
Other |
|
|
|
|
Ownership agreement |
|
For payment, submit bill on pink |
|||||||
|
|
|
|
|
|
|
|
|
|
“Statement for Retraining and Job |
||||
Assembly, installation & delivery |
|
|
|
|
|
|
|
AND |
|
Modification Services” form (F245- |
||||
|
|
|
|
Bids (2 bids if single item |
|
|||||||||
|
|
|
|
|
|
|||||||||
|
|
|
|
|
|
application. |
|
|||||||
|
|
|
|
|
|
over $2,500) |
|
|
||||||
Tax |
|
|
|
|
|
|
|
|
|
|
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Vendor name |
|
|
|
|
|
||||
Total |
$ |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Address |
|
|
|
|
|
||||
Employer’s portion of costs |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
City |
|
|
|
|
|
|
State |
|
ZIP+4 |
|
|
|
|
|
|
|
|
|||||||
State Fund or |
|
|
|
Provider number |
|
|
Phone number |
|||||||
|
|
|
|
|
|
|
||||||||
|
|
|
|
|
||||||||||
Date |
Vocational counselor or consultant signature |
|
|
Employer signature (if contributed to costs) |
||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
For Dept Use Only
Approve |
Authorization code (0380R) |
|
entered on AUTH |
Authorization amount entered on CLOG
Disapprove
Date |
Signature authority |
Index:
JMOD
Ownership Agreement for Tools and Equipment
Purchased as a Job Modification
Worker: ____________________________ |
Claim #: ____________________________ |
Employer:___________________________ |
|
This modification is being provided to accommodate my work restrictions so I may perform my job duties and return to work.
My employer and I will need to agree upon who will own the equipment and note it below. (Typically, a worker would be listed as the owner for any portable items.)
The designated party will own these items when I successfully return to work. Any equipment owned by the employer must remain available to me during my shift.
Maintenance Responsibility:
Safekeeping, proper maintenance and repair of the equipment (beyond the expiration of the manufacturer’s warranty, if applicable) are the responsibility of the identified owner.
Return Policy:
I will return any items to L&I if not used by me or if I am not able to successfully return to work. I will contact L&I and make arrangements to return the equipment to the nearest service location.
If the employer paid for any cost of the modification, or the equipment is affixed to the work site, the employer may retain the equipment, regardless of the outcome of the modification or return to work.
I understand the agreement above and I am willing to comply with the terms.
______________________________________________ |
__________________ |
Worker Signature |
Date |
______________________________________________ |
__________________ |
Employer Signature |
Date |
Inventory |
|
Equipment/model #
Owner (upon successful completion)
Index:
JMOD
INSTRUCTIONS FOR COMPLETING THE JOB MODIFICATION ASSISTANCE APPLICATION FORM
NOTE: |
SUBMIT A SEPARATE APPLICATION FOR EACH VENDOR. |
1)DATE OF INJURY: Record the date of injury.
2)CLAIM NUMBER: For the injured worker on whose behalf the application is being submitted.
3)INJURED WORKER’S NAME: Injured worker’s full name.
4)ACCEPTED DIAGNOSIS: Record the accepted industrial condition(s).
5)VOCATIONAL COUNSELOR/JOB MODIFICATION CONSULTANT: Record the name of the individual submitting the application (must be vocational counselor, job modification consultant, or employer that has been trained in completing the applications.) May not be submitted by the worker.
a)FIRM NAME: Record the firm that the vocational counselor/job modification consultant represents.
b)PROVIDER NO.: Record the vocational counselor/job modification consultant’s provider number.
c)ADDRESS: Record the vocational counselor/job modification consultant’s address, phone, and fax number.
6)JOB TITLE: Record the actual or anticipated job title for which the application is being submitted.
7)EMPLOYER NAME: Record the employer’s name and telephone number for the job title listed.
8)DESCRIPTION OF WORK RESTRICTIONS: List the restrictions or limitations in physical capacities that relate to the requested modification.
9)DESCRIPTION OF JOB MODIFICATION: Briefly list the equipment being requested and the reason for the request.
10)ITEMIZATION OF COSTS:
a)EQUIPMENT: Record the cost of equipment being requested.
b)TOOLS: Record the cost of any tools being requested.
c)OTHER: Record the cost of
d)ASSEMBLY: Record the cost of assembly, installation and delivery.
e)TOTAL: Record total cost of modifications requested for this vendor.
f)EMPLOYER’S PORTION: Record the amount the employer will pay to the vendor.
g)STATE FUND (SF) OR
11)REQUIRED DOCUMENTATION
a)REPORT: If the report has been previously submitted, please indicate that it is “on file”.
b)BIDS: Submit two bids for any item over $2,500.00. The price includes any tax, shipping, delivery, and training charges. If the item is only available from one vendor, please specify that it is a sole source item.
c)OWNERSHIP AGREEMENT: Submit completed form
12)VENDOR: Enter the vendor’s name, address, phone and provider number. Vendors must have a provider number in order to be reimbursed.
Index:
JMOD