Verification Of Employment Form And Disclaimer Statement Page 2
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2EARLY CHILDHOOD SCHOOL READINESS PROGRAMS
DISCLAIMER STATEMENT
According to the Office of Early Learning (OEL) Rule 6M-4.203(2) (b)
“A parent must notify the coalition, or its designee, of any change in employment, income, or family size within ten (10) calendar days”. A client that has a
loss/break of employment and reports it within the specified time frame may be able to maintain eligibility for financially assisted school readiness
services. Failure to do so will lead to the termination of your child care services. If a loss/break of employment is not reported within the specified time
frame, sanction penalties will be imposed.
CLIENT NAME: _____________________________________ LAST FOUR OF SSN:________________________
VERIFICATION OF EMPLOYMENT:
A. ( ) NEW/RE-ENTER CLIENT:
1. Your income must be verified before child care can be authorized.
2. All sections on the “Verification of Employment” form (reverse side) must be filled out by authorized personnel.
3. The form must be returned and information complete before child care can be authorized.
4. My signature below confirms I understand that in order to continue the child care services at the time of my
next recertification I must have 6-8 weeks of current check stubs/receipts if paid:
Weekly- 6 check stubs/receipts
Bi-weekly- 3 check stubs/receipts
Semi-monthly- 4 check stubs/receipts
Monthly- 2 check stubs/receipts
B. ( ) CLIENTS WHO HAVE CHANGED JOBS OR SHIFT HOURS:
1. Your income must be verified before child care can be authorized for more than 14 calendar days.
2. All sections on the “Verification of Employment “form (reverse side) must be filled out by authorized personnel.
3. The form must be returned and information complete no later than your recertification date of ________________,
or child care will be terminated.
4. My signature below confirms I understand that in order to continue the child care services at the time of my
next recertification I must have 6-8 weeks of current check stubs/receipts if paid:
Weekly- 6 check stubs/receipts
Bi-weekly- 3 check stubs/receipts
Semi-monthly- 4 check stubs/receipts
Monthly- 2 check stubs/receipts
__________________________________________________
_______________________
Client Signature
Date
VERIFICATION OF LOSS/BREAK OF INCOME OR EMPLOYMENT:
1. All sections on the “Loss/Break of Income or Employment” form (reverse side) must be filled out by
authorized personnel.
2. The form must be returned and information verified no later than your recertification date of ________________,
or child care services will be terminated.
__________________________________________________
_______________________
Client Signature
Date
SRP STAFF SIGNATURE: ______________________________________
DATE: ____________________
□ 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
Status Change Fax (813) 739-6042
RBM & Status Change Fax (813) 915-3236
Verification of Employment 4/23/15 – rev. 4/30/15
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