Verification Of Employment/loss Of Income Form printable pdf download

VERIFICATION OF EMPLOYMENT/LOSS OF INCOME

________________________________

Date: ____________________

________________________________

In order to determine the eligibility of _____________________________________________ for public assistance,

please assist us by answering the questions below and returning this form to us as soon as possible.

Office Address/Fax Number:

___________________________________________

Sarasota County Health Department

Client’s name

2200 Ringling Blvd

___________________________________________

Sarasota, FL 34237

Client’s date of birth

Fax: 941‐861‐2796

Please complete each section which is applicable or has been marked on Page 1 AND Page 2 of this form.

☐ Section I – GENERAL INFORMATION

1. Name of Employee:________________________________________ *Social Security Number:____________________

Address:_________________________________________________________________________________________

2. Job Title:_________________________________________ Type of Work Performed:___________________________

3. Number of Hours Worked Per Week:________________ Number of Days Worked Per Week:_______________

4. A. How often is/was the employee paid? ☐ Day ☐Week ☐ Bi‐Weekly ☐ Monthly

B. Rate of pay: $___________ per ___________ . Other ______________________________Hr./Day/Wk./etc. (Explain)

5. Date current employment began:___________________ Date previously employed:____________________________

6. Does/did employee receive tips? ☐Yes ☐ No (If yes, please show tips in Section III.)

7. Is/was employment seasonal? Yes No If yes, season begins:_______________ ends:___________________________

8. Is/was the employee covered by health insurance? ☐Yes ☐ No

If yes, name of insurance company:____________________________________________________________________

9. Number of dependents covered:________________

10. Does/did the employee participate in any type of payroll savings plan or profit sharing? ☐ Yes ☐No

If yes, what is the balance? $____________________

11. Does the person perform their job duties: ☐in their home ☐in your home ☐N/A

☐ Section II –VERIFICATION OF LOSS OF INCOME AND/OR UNPAID LEAVE

1. Date employment ended/Last day before unpaid leave:___________________________________

2. Reason for termination/unpaid leave:____________________________________________________________________

3. Is the loss of income Permanent or Temporary (ex. maternity leave)? If temporary, when do you expect the employee

to return to work? __________________________________________________________________________________

4. Date employee received final check:_______________________ Gross amount: $____________________

(Please list last 4 weeks in Section III.)

5. Will employee receive any vacation pay, retirement refund, or other? ☐ Yes ☐ No

If yes, what type? _____________________ Date received:___________________ Amount: $________________

6. Is employee eligible for any type of benefits from your company, such as extended insurance coverage, workers’

compensation, or other? Yes No If yes:

A. Name of insurance company:_______________________________________________________________________

B. Reason for benefits:______________________________________________________________________________

Verification Of Employment/loss Of Income Form

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