Letter To Verify Employment printable pdf download

Form 241

Revised 1/16

Letter to Verify Employment

The employer may submit a statement, on company letterhead, for verification.

The

statement must include:

1) The name of the individual receiving the income

2) The gross amount of income received

3) The frequency of income received (i.e. weekly, every two weeks,

twice a month, monthly or annually for seasonal or self-employed)

A sample letter could be written as follows:

This statement is to confirm that _______________________ is employed at

Name of Employee

_________________________.

Name of Employer

______________________ received a gross income (before deductions for

Name of Employee

taxes, social security, insurance, etc.) of $______________ on ___/___/___.

Date

The frequency of payment is:

Weekly

Every two weeks

Twice a month

Monthly

________________________/_____________

__________________

Signature of Employer

Title

Date

___________________________________

(____)_________________

Address

State Zip Code

Telephone Number

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil

rights regulations and policies, the USDA, its Agencies, offices, and employees, and

institutions participating in or administering USDA programs are prohibited from

discriminating based on race, color, national origin, sex, disability, age, or reprisal or

retaliation for prior civil rights activity in any program or activity conducted or funded by

USDA.

Persons with disabilities who require alternative means of communication for

program information (e.g. Braille, large print, audiotape, American Sign Language, etc.),

should contact the Agency (State or local) where they applied for benefits. Individuals who

are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal

Relay Service at (800) 877-8339. Additionally, program information may be made available

in languages other than English. To file a program complaint of discrimination, complete the

USDA

Program

Discrimination

Complaint

Form,

(AD-3027)

found

online

at:

, and at any USDA office, or write a letter

addressed to USDA and provide in the letter all of the information requested in the form. To

request a copy of the complaint form, call (866) 632-9992. Submit your completed form or

letter to USDA by mail: U.S. Department of Agriculture, Office of the Assistant Secretary for

Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410; fax: (202)

690-7442; or email: program.intake@usda.gov. This institution is an equal opportunity

provider.

Letter To Verify Employment

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