Employment Verification Form

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Community Coordinated Care for Children, Inc.
Orange County
Osceola County
3500 W Colonial Drive, Orlando, Fl 32808
2200 E.Irlo Bronson Mem Hwy Unit 7, Kissimmee, Fl 34744
(407) 522-2252
(321) 219-6300
Employment Verification Form
**Six-weeks current and consecutive paystubs are preferred for proof of employment and
will be required at your next interview. However, this form may be used on a one-time basis
or for new employment ONLY.**
General Information:
Name of Employee: ____________________________________ SSN: ____________________
Address: _____________________________________________________________________
Job Title: ________________________
Type of Work Performed: ____________________
Number of Hours Worked Per Week: ________
Number of Days Worked per Week: _____
How often is the employee paid?
Day
Week
Bi-Weekly
Monthly
Rate of pay: $________ per ________.
Other: ______________________________
Hr/Day/Wk
(Explain)
Date current employment began or date returned to work: ___________________________
Does the employee receive tips?
Yes
No
Is employment seasonal?
Yes
No
Does the employee work evenings and/or weekends?
Yes
No
Record of Pay Received: In the space below, list the gross amounts and dates of checks or
cash which were paid for the last six weeks:
Pay Period
Date Pay
GROSS
Number of
Rate of Pay
Number of
Tips
NET
Ending
Received
Earnings
Hours
Overtime
Earnings
Worked
Hours
Employer Information:
I declare that the above information is true and complete to the best of my knowledge. I know that if I
knowingly give wrong information, I am liable for prosecution under state law. Further, I give my
consent to Community Coordinated Care for Children, Inc., The Department of Children & Families, and
The Division of Public Assistance Fraud to make inquiry into all statements made above.
_____________________________________
_________________________________
Signature of Employer
Print Name (Employer)
Employer’s Title
_____________________________________
_________________________________
Name of Business
Telephone Number
_____________________________________
_________________________________
Address
Date Completed

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