Cy 925 - Employment Verification Form (Pennsylvania Department Of Human Services)
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1
2Employment Verification Form
EMPLOYER NAME/PLACE OF EMPLOYMENT:
IMMEDIATE SUPERVISOR’S NAME:
IMMEDIATE SUPERVISOR’S TITLE:
I authorize the release of this information and give permission to the Child Care Information Services (CCIS) agency to verify all information contained in this form.
EMPLOYEE’S PRINTED NAME
EMPLOYEE’S SIGNATURE
DATE
THE FOLLOWING SECTIONS MUST BE COMPLETED BY THEIR EMPLOYER
EMPLOYER IDENTIFICATION NUMBER (EIN):
ADDRESS OF EMPLOYMENT:
EMPLOYER’S TELEPHONE NUMBER:
(______) ______ - ____________
EMPLOYEE INFORMATION
EMPLOYEE’S JOB TITLE:
EMPLOYMENT START DATE:
Is the above-mentioned employee newly hired?
Yes
No
______ / ______ / ____________
EMPLOYMENT INCOME
HOURLY RATE:
GROSS PAY:
AVERAGE DAILY TIPS:
NEXT PAY DATE:
PAY FREQUENCY:
Weekly
Bi-Weekly (26 pays/year)
Twice a Month (24 pays/year)
Monthly
$
$
$
___ / ___ / ______
The employee:
receives paystubs
does NOT receive paystubs
has access to pay online via the following website:
EMPLOYMENT SCHEDULE (Please indicate the days and hours the employee works and indicate whether the hours occur during A.M. or P.M.)
NOTE: If the schedule varies, please give a 4-week sample schedule.
WEEK ONE
WEEK TWO
WEEK THREE
WEEK FOUR
Dates: from: _________________
Dates: from: _________________
Dates: from: _________________
Dates: from: _________________
to: ___________________
to: ___________________
to: ___________________
to: ___________________
Mon.
from ________ a.m./p.m. to ________ a.m./p.m.
Mon.
from ________ a.m./p.m. to ________ a.m./p.m.
Mon.
from ________ a.m./p.m. to ________ a.m./p.m.
Mon.
from ________ a.m./p.m. to ________ a.m./p.m.
Tues. from ________ a.m./p.m. to ________ a.m./p.m.
Tues. from ________ a.m./p.m. to ________ a.m./p.m.
Tues. from ________ a.m./p.m. to ________ a.m./p.m.
Tues. from ________ a.m./p.m. to ________ a.m./p.m.
Wed. from ________ a.m./p.m. to ________ a.m./p.m.
Wed. from ________ a.m./p.m. to ________ a.m./p.m.
Wed. from ________ a.m./p.m. to ________ a.m./p.m.
Wed. from ________ a.m./p.m. to ________ a.m./p.m.
Thur. from ________ a.m./p.m. to ________ a.m./p.m.
Thur. from ________ a.m./p.m. to ________ a.m./p.m.
Thur. from ________ a.m./p.m. to ________ a.m./p.m.
Thur. from ________ a.m./p.m. to ________ a.m./p.m.
Fri.
from ________ a.m./p.m. to ________ a.m./p.m.
Fri.
from ________ a.m./p.m. to ________ a.m./p.m.
Fri.
from ________ a.m./p.m. to ________ a.m./p.m.
Fri.
from ________ a.m./p.m. to ________ a.m./p.m.
Sat.
from ________ a.m./p.m. to ________ a.m./p.m.
Sat.
from ________ a.m./p.m. to ________ a.m./p.m.
Sat.
from ________ a.m./p.m. to ________ a.m./p.m.
Sat.
from ________ a.m./p.m. to ________ a.m./p.m.
Sun.
from ________ a.m./p.m. to ________ a.m./p.m.
Sun.
from ________ a.m./p.m. to ________ a.m./p.m.
Sun.
from ________ a.m./p.m. to ________ a.m./p.m.
Sun.
from ________ a.m./p.m. to ________ a.m./p.m.
TOTAL # HOURS/WEEK: _________________________
TOTAL # HOURS/WEEK: _________________________
TOTAL # HOURS/WEEK: _________________________
TOTAL # HOURS/WEEK: _________________________
Effective begin date of schedule change:
EXTENDED LEAVE
___ / ___ / ______
___ / ___ / ______
Is the employee on extended leave (maternity, disability, etc.)?
Yes
No
Effective begin date of extended leave:
Date returned from extended leave:
TEMPORARY/SEASONAL EMPLOYMENT
___ / ___ / ______
Is the employee considered to be a temporary hire?
Yes
No
If the employee is considered a temporary hire, what is the last date of guaranteed employment?
___ / ___ / ______
___ / ___ / ______
If the employee is seasonal, please give:
Last day of work before break:
Expected date of return following break:
I understand that the information I am providing will be used to determine the above-named employee’s eligibility for subsidized child care.
EMPLOYER’S PRINTED NAME & JOB TITLE
EMPLOYER’S SIGNATURE
DATE
CY 925 12/15
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