Employment Verification Form - Early Learning Coalition Of Seminole
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1Employment/Income Verification Form
In order to determine eligibility for a child care scholarship, the ELC must receive copies of the most current consecutive six weeks
pay stubs or this form, completed by the employer, as documentation of a new job or if paystubs are not issued.
(To be completed by employer)
SECTION I – GENERAL INFORMATION:
1. Employee Name: ______________________________________________________ SS#______________________________
Employee Address: _______________________________________________________________________________________
2. Type of work performed by employee: ______________________________ Employment began:_______________________
3. Number of hours worked:
Per week: ___________
Number of days per week: __________________
Work schedule:
From:
___________________
To: ______________________
A.M.
P.M.
Circle Days of Work:
Sunday Monday Tuesday Wednesday Thursday Friday Saturday
4. Hourly wage received by employee: $______________
Date employment ended: ___________________
5. Employee paid: $_______________
Weekly
Bi-weekly
Semi-monthly
Monthly
Other
6. Does employee receive tips?
Y
N
If Yes, show tips in Section III
7. Is employment year-round?
Y
N
If No, specify # of months:
12
11½
11
10½
10
9½
9
Other: ________
(To be completed by employer)
SECTION II – EMPLOYER INFORMATION:
1. Employer Name: _______________________________________________________
Title: _______________________
2. Business Name: _______________________________________________________
Phone #: ____________________
3. Business Address: _________________________________________________________________________________________
(To be completed by employer)
SECTION III – RECORD OF PAY RECEIVED:
1.
In the space below, list the most current and consecutive SIX weeks of checks or cash received by the employee along with the gross amount
paid, hours worked and the date the checks or cash were issued.
DATES OF PAY PERIOD
DATE OF PAYMENT
GROSS EARNINGS
# OF HOURS WORKED
TIPS
NET PAY
2. Please explain any unusual gaps or overtime and do you expect them to reoccur? _____________________________________
________________________________________________________________________________________________________
SECTION IV – EMPLOYER VERIFICATION:
I certify under the penalty of perjury (a first degree misdemeanor punishable by a definite term of imprisonment, not exceeding one year and/or a
fine not exceeding $1,000 pursuant to s. 837.012, or 775.082, or 775.083, F.S.) the information provided on this form is true and complete to the
best of my knowledge. I know if I give false information on purpose, I may be subject to prosecution for fraud.
______________________________________________
________________________________________________
Employer Signature
Title
Employer Name (Print or Type)
Date
Effective 6/11/14
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