Louisiana Medicaid Program Wage Verification Request Form Page 2
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21. Name of Employee
Social Security Number
Address of Employee
Name of Employer
Date Started
Date Expected to Start
2. If terminated, give: Last Day Worked ______________ Amount of Last Check $_______________
3. Check how often the employee is (was or will be) paid and complete the chart below. Please give us
gross pay before any deductions.
Weekly (show 4 most recent)
Twice Monthly (show 2 most recent)
Every Two Weeks (show 2 most recent)
Monthly (show 1 most recent)
Period
Date Wages
Number of
Gross Pay
Federal
State
Medicare
Social
Ending
Received
Hours
OR
Tax
Tax
Tax
Security
(not applicable
OR
Worked OR
Anticipated
Withheld
Withheld
Withheld
Paid
to anticipated
Anticipated
Anticipated
Pay
wages)
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
4. If taxes are not withheld, please explain why. _____________________________________________
_________________________________________________________________________________
5. If this person is a contractor, will IRS Form 1099 be issued?
Yes
No
6. Is/was employee covered by health insurance?
Yes
No If yes, please provide:
Name of Insurance Company _________________________________________________________
Claims Filing Address _______________________________________________________________
Policy # ______________________________
Date of Entitlement _______________________
Type of Coverage
_____________________________________________
(group, hospital, major medical)
Who is/was covered? ________________________________________________________________
What is the monthly premium amount? _________________________________________________
_________________________________
_______________
(______)________________
Signature of Employer
Date
Telephone Number
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Parent category: Medical