Earnings Verification
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1STATE OF NEVADA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
DIVISION OF WELFARE AND SUPPORTIVE SERVICES
TANF
MEDICAID
SNAP
┌
┐
Date:
Case Name:
SSN:
Case Manager
Signature:
AUTHORIZATION: I authorize you to release to the Division of
└
┘
Welfare and Supportive Services the requested information.
ATTENTION: Payroll Department
Client Signature
Date
EARNINGS VERIFICATION
Please provide the information for each of the items checked below and return to the above address. Your cooperation will help insure
integrity and maintain accountability in the administration of public funds in Nevada. The information provided us will be used only in
conjunction with the official duties of this department and will be considered confidential.
If our identifying information (name, Social Security number or address) does not agree with your records, please indicate the change.
RE:
Name
Social Security Number
Employee’s Address:
1. Date work began:
Number of hours employee is scheduled to work per week:
2. Hourly rate of pay $
Average hours worked per week:
Date of first paycheck:
3. How often are paychecks issued:
Weekly
Bi-weekly
Semi-monthly
Monthly
When are regularly scheduled paydays?
4. Will “tips” be received?
YES
No If YES: Estimated amount: $
per
5. Is this employment Contractual?
YES
No If YES: Contracted wage amount: $
per
Maximum Earnings provided in contract: $
Number of months covered by this contract:
6. Are/Were wages funded in whole or in part by Workforce Incentive (formerly JTPA?) Programs?
YES
NO
If YES, through:
Work experience
OR
On-the-job training
7. Please list below all monies (earnings, sick pay, vacation pay, disability, etc.) PAID or ANTICIPATED TO BE PAID
(regardless of when earned to the employee in the month of):
HOURS
GROSS WAGES PAID
PAY PERIOD
WORKED
ACTUAL
(Include special allowances such as meals, uniforms,
ENDING
PER PAY
DATES PAID
FICA
FITW
etc., and show a break-out of such amounts)
8. Do you anticipate any change in the number of hours, rate of pay or paydays next month:
YES
NO
If YES, please explain the change.
9. Is Medical Insurance available to the employee?
YES
NO If YES, is the employee enrolled?
YES
NO
If YES, provide the policy #
Effective Date:
End Date:
Names of dependents covered:
10 If this person is NOT working for you at this time, complete the following information:
DATE
Quit
Fired
Reason for leaving:
Leave of absence
Expected date of return:
Applied Workers Comp.
Date of final check:
Gross amount: $
Signature of Employer
Title
Telephone Number
Date
DISTRIBUTION: WHITE - Employer; CANARY - Suspense
2074 - EG (11/08)
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