Employer Verification Of Earnings Page 2
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3WISCONSIN DEPARTMENT OF HEALTH SERVICES
EVFE
Division of Health Care Access and Accountability
F-10146 (07/08)
EMPLOYER VERIFICATION OF EARNINGS
MUST BE COMPLETED BY THE EMPLOYER (Instructions on the back)
Please return this form by: <Date to Return>
to <Return Address - Page 1>
EMPLOYER INFORMATION
EMPLOYEE INFORMATION
<Employer Name>
<Employee Name>
<Employer Address>
<Employee Address>
<City, State, Zip>
<Employee City, State, Zip>
<FEIN>
<Fax>
<Case/PIN>
SECTION 1 – EMPLOYMENT STATUS
Is the employee listed above currently employed by your company?
Yes
No If yes complete Section 2.
If “No”, Indicate employment end date
/
/
Reason employment ended
Never Employed
Laid Off
Quit
Strike
Fired
Other
Date of final paycheck:
/
/
Gross pay for final month: $
SECTION 2 – EMPLOYMENT INFORMATION
Start date of employment
/
/
Date first paycheck received
/
/
Employee Type
Temporary
Permanent
Title
Manager
Other
Please provide an estimate of the following wage information for the next 30 days.
Type of Pay
Best Estimate of Hrs Rate of Pay
Regular Scheduled
Worked Per Week
Per Hour
Work Hours
Regular
$
Overtime
$
Other Shift Pay
$
Weekend /Shift Differential pay
$
Holiday Pay
$
Other
$
Gross Per Pay Period
Salary if not paid hourly
$
Bonus and/or Commissions
$
Cash and/or Tips
$
Frequency of pay
Weekly
Bi-Weekly
Semi-monthly
Monthly
Irregular
SIGNATURE - Employer / Designee
Date Signed
Print Name
Telephone Number
Title
Fax Number
COMMENTS
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