AGREEMENT to Modify the ITA Referenced Above Made by and Between

Career Counselor Worksheet
ITA MODIFICATION
For use with WIOA Funded Individual Training Account

Oakland Workforce Development Board (OWDB)
KRA ITA/PO NUMBER:
MODIFICATION NO.
This is a fillable Word form. Click on to begin then tab to each box.

AGREEMENT to modify the ITA referenced above made by and between:

KRA: / KRA Corporation
ADDRESS: / 24301 Southland Drive, Suite 401, Hayward, CA 94545
CONTACT: / Hannah Bell
PHONE: / (510) 736-7222 / FAX: / (510) 298-5973 / EMAIL: /
PROVIDER: >
ADDRESS: / CITY/ST/ZIP:
CONTACT: / TITLE:
CONTACT PHONE: / FAX: / EMAIL:
PARTICIPANT INFORMATION
WIOA REGISTRANT: / APP # / SSN4:
CASE MANAGER: / CENTER:
PHONE: / FAX: / EMAIL:
COURSE TO BE MODIFIED:
PARTICIPANT’S WIOA PROGRAM: / -- Select One --Adult (A)Dislocated Worker (DW)Other
1. ITA TERM:
a. / Existing ITA Training Period: / To:
b. / New ITA Training Period, if changed by this Modification: / To:
c. / ITA Total Course Hours:
d. / New Course Hours, if changed by this Modification:
2. ITA OBLIGATION:
a. / Existing ITA Amount: / $
b. / ITA Increase (+) or Decrease (-), if changed by this Modification: / $
c. / New ITA Total, if changed by this Modification: / $ / 0.00
MODIFICATION PURPOSE: / (600 characters)

By signing and transmitting this ITA Modification, the undersigned intends that KRA Corporation rely upon and act in accordance with all of the information contained herein. The AJCC is certifying to the accuracy of the information being supplied on this document. You must notify KRA of any changes in customer activities, and/or any discrepancies in support documents affecting this ITA Modification.

Case Manager: / Site Manager:
PRINT NAME: / Date / PRINT NAME: / Date
TITLE: / TITLE:

WDB signature required if the new obligated amount is greater than the previous ITA Request, or if a new/different course is requested.

WDB Staff Manager:
PRINT NAME: / Date
TITLE:

Revised: 12/14/17 – KRA2017