Employment Verification Form
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1EMPLOYMENT VERIFICATION FORM
An application for Economic Support benefits was submitted to the Georgia Crime Victims Compensation
Program (CVCP) for consideration. To help the CVCP make the best possible decision in determining
eligibility, we would appreciate your assistance by providing the below information.
Employee/Victim
Name: _______________________________________
Last 4 of SSN: ___________________
Address: _____________________________________
DOB: _____/_____/_____
Date of Crime: _____/_____/_____
Claim Number: ___________________
1. Dates of employment:
From: ____/____/____
To: ____/____/____
2. Hourly Wage: $ ___________________
Annual Salary: $ ___________________
Employment type: Full-time
Part-time
Number of hours worked per week _________
3. Work dates missed due to victimization, OR
From: ____/____/____
To: ____/____/____
employee/victim did not miss any days from work:
Check here if no work days missed
4. Total amount of wages lost due to victimization.
$ _________________
5. Dates of paid leave: None
Annual
Sick
Sick & Annual
From: ____/____/____
To: ____/____/____
Other:_____________________________
6. Disability pay:
Yes
No
If Yes, what type:
Short-Term
Long-Term
Worker’s Compensation
Amount:
$ _________________
Dates of disability pay:
From: ____/____/____
To: ____/____/____
__________________________________________
___________________________________________
Company Name (print name)
Employer (print name)
___________________________________________
Employer Signature
Date: _________/_________/____________
Telephone No.: _______-_______-________
PLEASE NOTE:
TO BE VALID, please attach this form to a blank copy of the employer’s business letterhead or
business card that includes the business address/contact information AND the documents must be
faxed or mailed by the EMPLOYER.
An Equal Opportunity Employer
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