invoice – next level jobs · invoice – next level jobs state form 56566 (8-18) approved by...
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To: Next Level Jobs Program INVOICE NUMBER:
Department of Workforce Development Invoice Date: mm/dd/yyyy
Attn: Employer Engagement
10 N Senate Ave Total Award Amount:
Indianapolis, IN 46204
317‐232‐6698
nextleveljobs@dwd.in.gov
Grant Title:
SSN (last four
digits)
Birth Date
(mm/dd/yy)
Occupation (Must be
from occupation list:
http://www.nextleveljo
bs.org/Eligible‐
occupations.pdf) Name of training
Hire Date
(mm/dd/yy)
Training Period
Begin Date
(mm/dd/yy)
Wage at start of
Training/Wage
at completion of
Training
Six month
retention date
(mm/dd/yy)
Training Cost for
this employee
(Not to exceed
$5,000.)
Total Due This Invoice:
Employer Training Balance
Grantee Printed Name
Please Remit Payment To: Date:
EmployerGrantee Signature (mm/dd/yyyy)
Address 1
Address 2DWD Approver Printed Name
Address 3 Date:
TelephoneDWD Approver Signature (mm/dd/yyyy)
Invoice – Next Level JobsState Form 56566 (8-18)Approved by State Board of Accounts, 2018Approved by Auditor of State, 2018
Cannot exceed $50,000.
Must equal total in cell K45.
Employer Training Grant
Employee Name (first, last)
I certify that all expenditures reported or payment requested are for appropriate purposes and in
accordance with the provisions of the employer training guidelines and voucher. I hereby certify that
the foregoing information is accurate, activities have been performed in accordance with programs,
guidelines and the amount claimed is legally due, after allowing all just credits and that no part of the
same has been paid.
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