Form Dcf-Exh - Retp Employment Verification / Economic Status Form
Download a blank fillable Form Dcf-Exh - Retp Employment Verification / Economic Status Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Dcf-Exh - Retp Employment Verification / Economic Status Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1RETP EMPLOYMENT VERIFICATION / ECONOMIC STATUS FORM
Client Name: _____________________________
Employer Name: _______________________________
Alien#: __________________________________
Employer Phone#: ______________________________
Last 4 Digits of SSN:_____________________
Employer Fax#: ________________________________
To Be Completed By The Employer
Hire Date: _______________
Position: _______________________
Hourly Wage:_____________
Hours Per Week: ____________
Health Insurance available to this employee within 6 months of hire? ______ Yes _____No
Are you satisfied with this employee’s performance? ______Yes
_____ No
If no, please comment:_______________________________________________________
Contact Person: _______________________________
Title: ____________________
(please print)
Signature: ___________________________________ Date: ____________________
Is client actively working as of Today’s Date? _____ Yes _____No
If No, please provide Termination Date: ___________________
Verification Method Code: _______
F= Fax, E =In person with Employer, C= Client Contact with pay stub, O = Other – Specify.
or Refugee Services Provider Use Only
Regular
________ CL ________
Self________
Service Closure Date ___________
____Yes ___No
Intake Date ________ 90 Day Due________ 180 Day Due ________
Has Client Achieved ESS?
If unable to contact the employer, complete the information above and a attach copy of the latest paycheck.
Check stub must be maintained in the client file and client must sign below: ________________________________
(indicate dates included on paycheck stub)
If the client is unemployed, circle the applicable reasons.
If the client is facing barriers to effective resettlement and
(circle only one)
economic self-sufficiency, circle the applicable reason(s);
(1) Registered with RS funded employment provider
(a) Lack of transportation
(2) Laid off from most recent job
(b) Lack of child care
(3) Dismissed (fired) from most recent job
(c) Immigration status/employment authorization
(4) Quit most recent job
(d) Health problems
(5) Not seeking for health reasons
(e) Mental health problems
(6) Primary care provider for children
(f) Lack of English skills
(7) Registered with local workforce board
(g) Lack of housing / stable living arrangement
(8) Has employment waiting – needs authorization
(h) Lack of occupational skills
(9) Not seeking employment
(i) Acculturation challenges
(10) Significant barriers to resettlement (mental health, domestic
(j) Looking for employment, yet cannot find job
violence, housing, cultural resistance, etc.)
(11) Contract Manager approved exemption
Customer Signature: _____________________________
Date: ____________________
Service Provider Signature:_____________________
Date:____________________
DCF-EXH
R11/29/2010
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal