Arkansas Department of Human Services
Verification of Earnings
To determine eligibility and correct benefits for your employee we need the information requested below. This will
enable us to ensure that the public funds are used only for the actual and correct benefits to which a household
is entitled. PLEASE COMPLETE THE ITEMS CIRCLED AS WELL AS THE SIGNATURE SECTION AT THE BOTTOM
OF THIS FORM.
If you need this material in a different format such as large print, contact your local DHS county office.
Address Department of Human Services
SSN of Employee
1. The above employee began work __________ and earns $_________ per hour. He/she works an average of
_______ hours per week. Date first pay to be received _________.
Anticipated gross amount of 1st pay $_________.
Employee is paid:
Other -- Please indicate how often _______________
Every 2 weeks
2. Please show GROSS EARNINGS (before any deductions) PAID TO this employee as indicated. Please list each
pay check separately including vacation pay and bonuses.
Paid above wages
REC’D in the Month
For the past
3. Earnings: Are any of the earnings funded by JTPA - On The Job Training Program?
4. Termination: If employee no longer is employed by you, what was the date and reason for leaving this job?
Date last check will be received __________________ and gross amount _______________________
5. Additional Information/Expected Changes: (such as layoffs, raises, increased or reduced hours, vacation pay,
bonuses, and sick pay).
6. Insurance: If employee has insurance through this job, what is the name and address of the insurance
Claims processing address if different than insurance carrier ______________________________________________
Policy Number _______________________________ Effective date of policy ________________________________
Type of coverage __________________________________________________ Policy:
Policyholder and covered individuals _________________________________________________________________
I do hereby certify that the above information is factual and correct to the best of my knowledge.
Employer/Payroll Clerk Signature
Place of Business
DCO-97 (R. 2-91)-100970