Employment Verification Form
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1Employment Verification Form
In order to determine eligibility for All MCAA programs, you may submit copies of the most current consecutive six weeks pay stubs or have
employer complete this form. We must verify both employment and income on the below listed client. Please assist us by completing and returning
this form to Manatee Community Action Agency, Inc. as soon as possible.
SECTION I – GENERAL INFORMATION: (To be completed by employer)
1.
Employee Name: ________________________________________________________ SS#______________________________
Employee Address: ________________________________________________________________________________________
2.
Type of work performed by employee: ________________________________Employment began:________________________
3.
Number of hours worked per week: ___________ Number of days per week: ___________________________
Work schedule: From: _____________________ To: ______________________ [ ] A.M.
[ ] P.M.
Circle Days of Work: Sunday Monday Tuesday Wednesday Thursday Friday Saturday
4.
Hourly wage received by employee: $______________ Date employment ended: ________________________
5.
Employee paid: $_______________ [ ] Weekly [ ] Bi-weekly [ ] Semi-monthly [ ] Monthly [ ] Other
6.
Does employee receive tips? [ ] Y [ ] N (If yes, show tips in section III).
7.
Is employment year round? [ ] Y [ ] N
If no, Specify: 12 mos____11 ½ mos___ 11mos____
10 ½ mos____ 9 ½ mos_____ 9mos_____ Other __________
SECTION II – EMPLOYER INFORMATION:(To be completed by employer)
1.
Employer Name: ____________________________________________________________ Title: _______________________
2.
Business Name: _________________________________________________________ Phone #: _______________________
3.
Business Address: ________________________________________________________________________________________
SECTION III – RECORD OF PAY RECEIVED: (To be completed by employer)
1.
In the space below, list the most current and consecutive SIX weeks of checks or cash received by the employee along with the gross amount
paid, hours worked and the date the checks or cash were issued.
DATES OF PAY
DATE OF PAYMENT
GROSS EARNINGS
# OF HOURS
TIPS
NET PAY
PERIOD
WORKED
2.
Please explain any unusual gaps or overtime and do you expect them to reoccur? ________________________
__________________________________________________________________________________________
SECTION IV – EMPLOYER VERIFICATION:
The information provided on this form is true and complete to the best of my knowledge. I know that if I give false information on purpose, I may be
subject to prosecution for fraud. Self-Employment must be documented by submitting Employment Log or business records and receipts for
expenses.
______________________________________________
________________________________________________
Employer Signature
Title
Employer Name (Printed or Typed)
Date
Manatee Community Action Agency, Inc.
302 Manatee Ave E. Suite 322
(MCAA Emp/Inc Verification Form) Revised 8/10
Bradenton, Florida 34208 Phone: (941) 827-0188 Fax: (941) 827-0193
All Previous Forms are Voided
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Parent category: Legal