Child Care Services Employment/income Verification - Workforce Solutions
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1
2CHILD CARE SERVICES
EMPLOYMENT/INCOME VERIFICATION
Employee Name:
TWIST ID:
NOTE TO EMPLOYER: This is your authorization to release the information concerning my employment as required below.
In order to establish eligibility for child care services, verification of income is needed. Please complete this form as soon as
possible as it is required before I, or a member of my family, can be determined eligible for the program.
Your cooperation and prompt return of this information is appreciated. For questions, or to complete by phone, please
contact: WFS East Texas Child Care Services (CCS) at 1-800-676-8283.
Thank you,
Date:
Signature of Employee
Employer’s Name:
________________________________________________________________________________
Street Address:
__
City:
__________
_______ State:
_
Zip:
______ Telephone:
_______________ ___ __
Please verify income actually received for the period:
/
/
to
/
/
(WFS staff complete)
TO BE COMPLETED BY THE EMPLOYER
Employed From:
/
/
to
/
/
Position:
__________________________
Month/ Day/ Year
Month/ Day Year
Pay Rate:
per
Total hours for specified period:
___
hour / week / month
(date listed in grey section)
(circle one)
Gross income (including deductions) for specified period (dates listed in gray section):
__
(do not include bonuses/commissions in this total)
Were any bonuses/commission received for the specified period
YES or NO (
(dates listed in grey section)
circle one)
If YES, amount:
__ When are bonuses received by employee (i.e., monthly, quarterly, yearly): _
___
Do pay checks have Federal Income Tax, Social Security Tax & Medicare Tax withheld?
YES or NO
(circle one)
Average Number of Hours Scheduled per Week:
___ Typical Work Schedule
: _____________
(i.e., Monday – Friday 8-5:00)
Pay Frequency:
Weekly
Every Two Weeks
Twice a Month
Monthly
_____________________________________________________________________________________________________
Name and Title of Employer Representative (PLEASE PRINT)
_________________________________________________________
________________________________________
Signature of Employer Representative
Date
Equal opportunity employer/program
Auxiliary aids and services available upon request to individuals with disabilities
Relay Texas: 1-800-735-2989 (TDD) or 7-1-1 (Voice)
Revised 10/05/2016
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