Form Cc36 - Employment Statement - Child Care Assistance Program printable pdf download

Office Use Only

CHILD CARE ASSISTANCE PROGRAM

Division of Public Assistance

Child Care Program Office

3601 C Street, Suite 140

PO Box 241809, Anchorage, AK 99524-1809

EMPLOYMENT STATEMENT

Proof of Income

We need proof of your income to determine your eligibility. You can provide this information to your caseworker or your

employer can contact your caseworker directly. This form can be used as a way of providing this needed information.

This form is not mandatory. To use this form, fill out the Employee Section and ask your employer to fill out the

Employer Section and sign it. Return the form with your employer’s signature to your caseworker.

Employee Section (with my signature, I authorize release of the information on this form)

Employee’s Name: _________________________________

Employee Signature: _____________________________

Place of Employment: _______________________________________________________________________________

Social Security Number, optional: ____________________________

Employer Section (to be completed by Employer’s Human Resource or Payroll Representative)

Employer Representative’s Name: ______________________________________________________________________

Employer Representative’s Signature: ____________________________________ Contact Phone: _________________

Employee’s Gross Monthly Wage: ____________ Hourly Rate: ______ # Hours/Week: _____ # Days/Week: ______

Employee’s Typical Work Schedule: ____________________________________________________________________

□ Full Time

□ Part Time

□ Temporary □ On-Call

□ Seasonal

Is the Job:

□ Weekly

□ Every Two Weeks

□ Twice a Month □ Monthly

How Often Paid:

□ Tips

□ Room and Board

□ Commissions

□ Bonus

Other Compensation:

Monthly Amount of Other Compensation: ____________________________

List the information below or Attach the Employee’s Three (3) Most Current Paystubs:

Pay Period End Date

Date Pay Received

# of Regular Hours

# of Overtime Hours

Gross Pay

If New Employment: Employment Start Date:____________________

Date First Pay Issued: ______________

If No Longer Employed: Last Date Worked:_____________________

Date Final Pay Issued:__________________

Gross Amount of Final Pay:____________________

If only verifying employee’s work location please provide:

Work location (City/State): ____________________________________________ Date began at this location: _______

Family ICCIS Case Number:______________________

Caseworker Name:_______________________________________ Phone:_____________ Fax:___________________

CC36 (06-4064) Rev 07/15

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Form Cc36 - Employment Statement - Child Care Assistance Program

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