| CONSUMER: %consumer_name% (%consumer_id%) | WEEK OF: %weekof% |
| RATE: %rate% |
| EMPLOYEE: %employee_name% (%employee_id%) | EMAIL: %email% |
| FRIDAY (%date1%) | TUESDAY (%date5%) |
| Time In: %fri_hrin_1%:%fri_minin_1% Time Out: %fri_hrout_1%:%fri_minout_1% | Time In: %tue_hrin_1%:%tue_minin_1% Time Out: %tue_hrout_1%:%tue_minout_1% |
| Time In: %fri_hrin_2%:%fri_minin_2% Time Out: %fri_hrout_2%:%fri_minout_2% | Time In: %tue_hrin_2%:%tue_minin_2% Time Out: %tue_hrout_2%:%tue_minout_2% |
| Total Hours Worked: %fri_total% | Total Hours Worked: %tue_total% |
| SL: %fri_sl% | SL: %tue_sl% |
| SATURDAY (%date2%) | WEDNESDAY (%date6%) |
| Time In: %sat_hrin_1%:%sat_minin_1% Time Out: %sat_hrout_1%:%sat_minout_1% | Time In: %wed_hrin_1%:%wed_minin_1% Time Out: %wed_hrout_1%:%wed_minout_1% |
| Time In: %sat_hrin_2%:%sat_minin_2% Time Out: %sat_hrout_2%:%sat_minout_2% | Time In: %wed_hrin_2%:%wed_minin_2% Time Out: %wed_hrout_2%:%wed_minout_2% |
| Total Hours Worked: %sat_total% | Total Hours Worked: %wed_total% |
| SL: %sat_sl% | SL: %wed_sl% |
| SUNDAY (%date3%) | THURSDAY (%date7%) |
| Time In: %sun_hrin_1%:%sun_minin_1% Time Out: %sun_hrout_1%:%sun_minout_1% | Time In: %thu_hrin_1%:%thu_minin_1% Time Out: %thu_hrout_1%:%thu_minout_1% |
| Time In: %sun_hrin_2%:%sun_minin_2% Time Out: %sun_hrout_2%:%sun_minout_2% | Time In: %thu_hrin_2%:%thu_minin_2% Time Out: %thu_hrout_2%:%thu_minout_2% |
| Total Hours Worked: %sun_total% | Total Hours Worked: %thu_total% |
| SL: %sun_sl% | SL: %thu_sl% |
| MONDAY (%date4%) | SUMMARY |
| Time In: %mon_hrin_1%:%mon_minin_1% Time Out: %mon_hrout_1%:%mon_minout_1% | TOTAL WORKED: %total_worked% |
| Time In: %mon_hrin_2%:%mon_minin_2% Time Out: %mon_hrout_2%:%mon_minout_2% | TOTAL SL: %total_sl% |
| Total Hours Worked: %mon_total% |
| SL: %mon_sl% |
| Employee Electronic Signature: %ESignature1% |
| (I certify that my time sheet is accurate and true...that I worked these exact hours with the Waiver Recipient named above.) |
| Consumer/Guardian Signature:____________________________________________________ |
| (I attest by my signature that the Waiver Staff named above provided services during the hours indicated.) |
| Form Submission Time: %_sfm_form_submision_time_% |