Employment Verification Request printable pdf download

City of Springdale

Community Development Block Grant Program

201 Spring Street

Springdale, Arkansas 72764

Phone: 750-8550 Fax: 750-8539

Community Development Block Grant Program

Housing Services Program

Revised 12/12/15

Employment Verification Request

Dear Sir/Madam:

The person identified below has requested assistance from the City of Springdale’s

Housing Services Program. Because eligibility for assistance is based on income, we

request information on the applicant’s current income. Verification of the applicant’s

income will be kept confidential and used solely for the purpose of establishing the

applicant’s eligibility.

Name: ______________________________________ Date of Request____________

St/Ave/Rd/PO Box: ______________________________________________________

City, State, Zip Code: ____________________________________________________

I authorize the release of the information requested below to the City of Springdale’s

Housing Services Program.

Applicants Signature_____________________________________________________

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EMPLOYER: Please complete and return to: City of Springdale, Housing Services

Program, 201 Spring St., Springdale, AR 72764

Applicant’s position held__________________________________________________

Applicant’s dates of employment: from __________________ to __________________

Applicant’s pay: If hourly how many hours per week does the employee work? _______

Hourly $________ Weekly $__________ Bi-monthly $_________ Monthly $_________

Applicant’s Employer:

Name________________________________________________________________

Address______________________________________________________________

I certify that the above information is true and correct

Signature of Employer ______________________________________ Date _________

Title _________________________________________________Phone #__________

HR-05 Employment Verification Form

Employment Verification Request