<Employer Name>
State of Wisconsin
<Employer Address>
<Employer Address>
<Employer Address>
Date:
<Today's Date>
Case Name:
<Case Name>
Case Number:
<Case Number>
Worker Name:
<Worker Name>
Worker Number: <Worker Number>
Telephone:
<Worker Telephone>
Questions: Ask your worker.
IMPORTANT REQUEST FOR EMPLOYMENT VERIFICATION
We have received information that <CLIENT’S NAME> is employed at <EMPLOYER’S NAME>.
Everyone who has a job must provide proof of the job and wages, even if they are no longer working at that job.
If you think this information is wrong, contact your local agency by the due date below.
Following are examples of what you can use:
The enclosed form,
Your pay stubs from the last 30 days, or
An employer statement that gives the same details as the enclosed form.
If you choose to use the enclosed form, take it to your employer and ask that s/he complete and sign this form.
Once the form is completed and signed, return the form to your local agency at the address listed above.
You must return this form or one of the other types of proof listed above by the due date below. It is your
responsibility to return this form or other proof of this job and wages to the local agency.
Program of Eligibility
Due Date
<Program>
<Due Date>
<Program>
<Due Date>
<Program>
<Due Date>
<Program>
<Due Date>
IMPORTANT NOTE: If you do not provide the required proof by the due date, your benefits will stop or your
application will be denied. If you have problems getting your employer to complete and/or return the form to you or
your employer asks you to pay a fee to complete the form, please contact your local agency right away.