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1、Department of Workforce Development Division of Employment and TrainingNew Student Cost Estimate WorksheetTo be completed by the Training InstitutionThe individual listed below may be eligible to attend your training institution under a deferred payment agreement through the State of Wisconsin, Depa
2、rtment of Workforce Development, Trade Adjustment Assistance (TAA) program or Workforce Investment Act (WIA) Dislocated Worker Services. Individuals are strongly encouraged to attend summer semesters to avoid loss of their weekly Trade Readjustment Assistance (TRA) allowances.Please return this form
3、 with a copy of the course curriculum, assessment results, documentation of acceptance into this program and any other relevant educational records. These forms need to be returned to the case worker before the course can be approved for payment.The individual must not enroll in any classes without
4、prior approval from their Case Manager.Personal information you provide may be used for secondary purposes Privacy Law, s. 15.04(1 )(m) Wis. Stats. Provision of your Social Security Number (SSN) is voluntary; not providing it could result in an information processing delay.Student NameStudent SSN or
5、 Student ID#Training InstitutionInstitution Federal ID#Training Institution AddressCityState ZipProgram of StudyStart DateAnticipated Graduation DateTotal CreditsEstimated number of semesters neededEstimated number of training weeks needed to complete training:Estimated Training CostTuition$Books$To
6、ols/Supplies/Uniforms (must be clearly stated on course syllabus and required for all students)$Registration Fee$Graduation Fee$Exam Fees - please list:$Other Fees - please list:$Sub-Total $Pre-Requisite or Remedial Courses Required (add+)Course numberCourse nameCreditsFeeSub-Total $Transferable Credits (minus )Course numberCourse nameCreditsFeeSub-Total$_Total Training Credits Total Costs$_Training Program RepresentativeCounselor SignaturePhone NumberEmailDate SignedTAA-16180 (R. 12/2009)White: TAA CoordinatorGreen: Participant
