Verification Of Employment Form - New York State Department Of Health

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Attachment IV
NEW YORK STATE DEPARTMENT OF HEALTH
Verification of Employment
Office of Health Insurance Programs
:
Name
___________________________________________________ App Reg./Case # : _______________________
Social Security Number: _______________________
Address: _________________________________________________________________________________________
City: _______________________________________ State: _______________________ Zip Code: _______________
For Office Use Only
To be completed by the employer:
I certify that _________________________ works for me as ______________________________________.
(What do you do?)
This employee is paid each (circle one):
Week
Two weeks
Twice per month
Does the employee have access to New York State Health Insurance?
Yes
No
Does the employee have dependents enrolled in his/her employer sponsored coverage?
Yes
No
Please supply the following information:
Last consecutive weeks
Date paid
Gross pay – Include tips, commissions and
bonuses
1
2
3
4
If no longer employed, date last worked: ___________________________________________
Business name: ______________________________________________________________________________________
Business address: ____________________________________________________________________________________
City: ___________________________________________
State: ____________________________________________
Zip: __________________________________ Business telephone: ___________________________________________
Employer’s name (please print): _________________________________ Title: _________________________________
Employer’s signature: _________________________________________ Date: _________________________________
DOH-XXXX (0X/10)

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