Fillable Printable Form 5418
Fillable Printable Form 5418
Form 5418
Page 1 of 2
JOB SEARCH WORKSHEET
State Form 54180 (R9 / 7-15) / IMP 0045
Job Search IMPACT Week: 1 2 3 4 5
Name of participant Case number RID number
IMPACT Program: Applicant Job Search TANF SNAP ABAWD
Name of IMPACT staff Telephone number
( )
Fax number
( )
Date
(mm/dd)
Company Name and Address
(number and street, city, state, and ZIP code)
Actual
Position
Applied For
Person
Contacted
(N/A, if Internet)
Telephone
Number
(N/A, if Internet)
Type of
Contact
Actual Time Spent
In Person
Telephone
Internet
Fax / Mail
Start Time End Time JS Travel Total Time
In Person
Telephone
Internet
Fax / Mail
Start Time End Time JS Travel Total Time
In Person
Telephone
Internet
Fax / Mail
Start Time End Time JS Travel Total Time
In Person
Telephone
Internet
Fax / Mail
Start Time End Time JS Travel Total Time
In Person
Telephone
Internet
Fax / Mail
Start Time End Time JS Travel Total Time
In Person
Telephone
Internet
Fax / Mail
Start Time End Time JS Travel Total Time
I certify that I have personally made the above contacts, and that this is an accurate record of my Job
Search activities. I understand that the information I have provided will be verified. I also understand that
providing false information or misrepresenting the truth to obtain services for which I am not entitled is a
crime which can be prosecuted under federal and/or state laws. The value of benefits received by a
person who was n ot eligible to receive t hem is sub ject to re covery by the State of In diana.
CONTACTS CHECKED ABOVE WERE VERIFIED BY TELEPHONE.
__________________________ ______________________ __________________
Signature of verifier
Date verified (mm/dd/yy)
Signature of Applicant / Recipient Date (mm/dd/yy)Signature of Case Manager / Reviewer Date (mm/dd/yy)
Reset Form
Page 2 of 2
Name of participant Case number RID number
Date
(mm/dd)
Company Name and Address
(number and street, city, state, and ZIP code)
Actual
Position
Applied For
Person
Contacted
(N/A, if Internet)
Telephone
Number
(N/A, if Internet)
Type of
Contact
Actual Time Spent
In Person
Telephone
Internet
Fax / Mail
Start Time End Time JS Travel Total Time
In Person
Telephone
Internet
Fax / Mail
Start Time End Time JS Travel Total Time
In Person
Telephone
Internet
Fax / Mail
Start Time End Time JS Travel Total Time
In Person
Telephone
Internet
Fax / Mail
Start Time End Time JS Travel Total Time
In Person
Telephone
Internet
Fax / Mail
Start Time End Time JS Travel Total Time
In Person
Telephone
Internet
Fax / Mail
Start Time End Time JS Travel Total Time
In Person
Telephone
Internet
Fax / Mail
Start Time End Time JS Travel Total Time
In Person
Telephone
Internet
Fax / Mail
Start Time End Time JS Travel Total Time
I certify that I have personally made the above contacts, and that this is an accurate record of my Job
Search activities. I understand that the information I have provided will be verified. I also understand that
providing false information or misrepresenting the truth to obtain services for which I am not entitled is a
crime which can be prosecuted under federal and/orstate laws. The value of benefits received by a
person who was n ot eligible to receive t hem is sub ject to re covery by the State of In diana.
CONTACTS CHECKED ABOVE WERE VERIFIED BY TELEPHONE.
__________________________________________________ ______________________
Signature of verifier
Date verified (mm/dd/yy)
__________________________________________________
Signature of Applicant / Recipient Date (mm/dd/yy)Signature of Case Manager / Reviewer Date (mm/dd/yy)
