Employment Verification
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1C o u n t y o f F a i r f a x , V i r g i n i a
To protect and enrich the quality of life for the people, neighborhoods and diverse communities of Fairfax County
EMPLOYMENT VERIFICATION
FAIRFAX COUNTY PROVIDES CHILD CARE ASSISTANCE TO LOW AND MODERATE-INCOME FAMILIES.
TO BE ELIGIBLE FOR THIS PROGRAM, WORKING PARENTS MUST DOCUMENT HOURS OF WORK AND
INCOME. PLEASE COMPLETE ALL INFORMATION REQUESTED BELOW.
Section I:
Employee to complete
Employee’s Name:
SSN: (optional)
Employee’s Address:
(street)
(city)
(zip)
Employee’s Home Telephone:
I authorize my employer to release information regarding my employment, salary and schedule.
Employee’s Signature
Date
Section II:
Employer to complete
1.
_________________________________ works for me ________ hours per week at an hourly rate of _________.
2.
This employee is paid:
_____ weekly
_____ biweekly (26 times/year)
_____ monthly
_____ semi-monthly (24 times/year)
3.
The employee does ________ / does not _________ receive paystubs. If the employee does receive paystubs according
to company policy, the next one will be issued: ________________.
4.
Does this employee’s work schedule vary from week to week?
Yes _____
No _____
5.
Complete employee’s schedule:
Employee’s Start Date: _______________________________________
Date
Hours Scheduled
Employer’s Name(please print): ________________________________
Mon
from:
to:
Employer’s Signature ________________________________________
Tues
from:
to:
Company or Organization: ___________________________________
Wed
from:
to:
Address: __________________________________________________
Thur
from:
to:
__________________________________________________
Fri
from:
to:
Employer’s Telephone: _______________________________________
Sat
from:
to:
Date: _____________________________________________________
Sun
from:
to:
Office for Children/Child Care Assistance and Referral
Department of Family Services
th
12011 Government Center Parkway, 8
Floor
Fairfax, Virginia 22035
703-449-8484, TTY 711, Fax 703-324-3917
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