Verification Of Earnings Form
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1Arkansas Department of Human Services
Verification of Earnings
TO EMPLOYER:
To determine eligibility and correct benefits for your employee we need the information requested below. This will
enable us to ensure that the public funds are used only for the actual and correct benefits to which a household
is entitled. PLEASE COMPLETE THE ITEMS CIRCLED AS WELL AS THE SIGNATURE SECTION AT THE BOTTOM
OF THIS FORM.
If you need this material in a different format such as large print, contact your local DHS county office.
Address Department of Human Services
Caseworker
Telephone Number
TDD#
Employee
Casehead
SSN of Employee
Case Number
1. The above employee began work __________ and earns $_________ per hour. He/she works an average of
_______ hours per week. Date first pay to be received _________.
Anticipated gross amount of 1st pay $_________.
Employee is paid:
Weekly
Monthly
Other -- Please indicate how often _______________
Every 2 weeks
Twice Monthly
2. Please show GROSS EARNINGS (before any deductions) PAID TO this employee as indicated. Please list each
pay check separately including vacation pay and bonuses.
Pay Period
Date
Hours
Housing/Utilities
Ending
Received
Worked
Gross Wages
Tips
Paid above wages
REC’D in the Month
January
of
For the past
consecutive pay
periods
3. Earnings: Are any of the earnings funded by JTPA - On The Job Training Program?
Yes or
No
4. Termination: If employee no longer is employed by you, what was the date and reason for leaving this job?
__________________________________________________________________________________
Date last check will be received __________________ and gross amount _______________________
5. Additional Information/Expected Changes: (such as layoffs, raises, increased or reduced hours, vacation pay,
bonuses, and sick pay).
______________________________________________________________________________________________
6. Insurance: If employee has insurance through this job, what is the name and address of the insurance
carrier?_________________________________________________________________________________________
Claims processing address if different than insurance carrier ______________________________________________
Policy Number _______________________________ Effective date of policy ________________________________
Type of coverage __________________________________________________ Policy:
individual or
group
Policyholder and covered individuals _________________________________________________________________
I do hereby certify that the above information is factual and correct to the best of my knowledge.
____________________________________________
_____________________
___________________
Employer/Payroll Clerk Signature
Date
Telephone
____________________________________________
____________________________________________
Place of Business
Address
DCO-97 (R. 2-91)-100970
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