Funds Use Verification Form:

Funds Verification Form:

Please note: the information provided on this form is what TCWD will use as the guidelines for how the awarded incentive funds need to be spent- this information should be accurate to the best of your knowledge. Any changes to this information need to be communicated to TCWD asap.
Practice Site Name*
Legal Name of Organization
Site Contact Name*

First NameLast Name
Site Contact Email*
example@example.com
Site Contact Phone*
Please enter a valid phone number.
Recruited/Retained Specialty:*

Family MedicineInternal MedicinePediatricsOBGYNPsychiatricDentistPsych NP
Clinician Name(s) and Employment Start Date(s):*
Total incentive funds awarded by TCWD per your agreement: *

Please indicate the dollar amount for each category that is planned to be used for the recruited/retained clinician: *

If other, please describe in detail how the funds will be used:
If multiple categories in "other" then please show the breakdown of funds for each category.
Additional comments:
Site Contact Signature: by signing below, the site agrees that this form will be used as a guideline for how the awarded incentive funds must be used. *

Clear
TCWD will review this document as soon as possible. TCWD will need to provide approval of this form before incentive funds are sent to the practice site. The practice site cannot start using the funds until TCWD has provided approval for appropriate use of funds.
Should be Empty:

Funds Verification Form: