Verification Of Employment Form And Disclaimer Statement printable pdf download

EARLY CHILDHOOD SCHOOL READINESS PROGRAMS

VERIFICATION OF EMPLOYMENT

***Do not alter or use white out on forms, only blue/black ink is acceptable.***

Date: ____________________________

Dear Employer:

In order to determine the eligibility of ___________________________________________ for financial assistance with the School Readiness (SR) Programs,

please assist us by completing this form and returning it to your employee as soon as possible. The employee has been given fourteen (14) calendar days to

return this form to our office.

DIRECTIONS: THIS FORM MUST BE COMPLETED BY THE EMPLOYER. THE INFORMATION WILL BE USED TO DETERMINE ELIGIBILITY FOR SERVICES FOR THE

EMPLOYEE BELOW:

**Current Employer Complete Section I, II & III >

Section I – Employee Information

Name of employee:________________________________________________________ Last four of SSN:____________________

Date current employment began:__________________________________ Date first pay is expected:_______________________

Rate of Pay: $__________per hour or $___________per day or $___________per week or $________per day month

Pay Schedule: □ daily □ weekly □ biweekly □ semimonthly □ monthly

Does the employee receive tips: □ Yes

□ No

* If yes, show tips in section II

How many hours per week does the employee work? _______________________________________________________

What shift does the employee work? □ Days

□ Afternoons □ Evenings

□ Varies Time:_____________________

Does the employee work weekends? □ Yes

□ No

Days scheduled off:____________________________________

Is the employment: □ seasonal

□ temporary □ permanent -- Season From_______________To_________________

What day of the week does the employee get paid on? _______________________________________________________

Section II – Payroll Record

In the table below, list the requested information for the most recent six (6) weeks:

Pay Date

Gross Earnings

Net Pay

Number of Hours

*Amount of Tips

Bonus/Commissions

Child Support

Worked

(if not known state amount customary

Deductions

for job performed)

If number of hours or rate of pay varies in the above pay periods, please explain: ________________________________________________________

Section III – Employer Information

The information written on this form is true and accurate to the best of my knowledge. I am aware that if I have given false information intentionally, I may be subject to

prosecution for fraud.

________________________________________

__________________________________________________

_____________________________

Name of Business

Business Address

Phone Number

________________________________________ ___________________________________________________ _____________________________

Signature of Person Completing Form

Title of Person Completing Form

Date

**Former Employer

ONLY >

Complete Section IV

Section IV – Loss/Break of Income or Employment

Name of employee:________________________________________________________ Last four of SSN:____________________

Date Employment Ended:__________________________________ Reason:______________________________________________________________________

Loss/Break of Income or Employment Termination is:

□ permanent

□ unpaid leave

□ temporary

* if unpaid leave or temporary, when will the employee return back to work?_______________________________________

The information written on this form is true and accurate to the best of my knowledge. I am aware that if I have given false information intentionally, I may be subject to

prosecution for fraud.

________________________________________

__________________________________________________

_____________________________

Name of Business

Business Address

Phone Number

_________________________________________ ___________________________________________________ _____________________________

Signature of Person Completing Form

Title of Person Completing Form

Date

SR Office use only: Loss/Break of Employment Verified by: ___________________________________________________ Date________________ Phone____________________________

Verified with: _______________________________________________________________________________________ Position_______________________________________________

Verification Attempts: (1) Date: ________________Time:______________ CSS : ___________________ (2) Date: _______________Time:_____________ CSS : ______________________

□ SR Brandon

□ SR North Tampa

□ SR Administrative office @ Net Park

9325 Bay Plaza, Suite 210

9309 N. Florida Ave., Suite 104

5701 E. Hillsborough Ave., Suite 2301

Tampa, FL 33619

Tampa, FL 33612

Tampa, FL 33610

PH (813) 740-4713 Fax (813) 740-4722

PH (813) 915-3200 Fax (813) 915-3239

PH (813) 744-8941 ext. 254 Fax (813) 744-6753