Verification Of Employment Form printable pdf download

*VerifFor*

APPENDIX C

Verification of Employment

Employed since: _____ Occupation: __________

OMMUNITY

ERVICES

EPARTMENT

OMMUNITY

Salary: _____________

SSISTANCE

IVISION

Effective date of last increase: _________

534 W

EST

AKE

ARY

LVD

, F

32773-7400

ANFORD

Base pay rate:

AME OF

$_____/Hour; or $_____/Week; or $_____/Month

:________________________

EMPLOYER

Average hours/week at base pay rate: ____ Hours

#____________________________

No. weeks ____, or No. weeks ____ worked/Year

Overtime pay rate: $______ /Hour

AUTHORIZATION: Federal Regulations

Expected average number of hours overtime

require us to verify Employment Income of

worked per week during next 12 months _______

all members of the household applying for

participation in the HOME Program which

Any other compensation not included above

we operate and to reexamine this income

(specify for commissions, bonuses, tips, etc.):

periodically. We ask your cooperation in

For: _______________ $______ per ________

supplying this information. This

information will be used only to determine

Is pay received for vacation?

• Yes

• No

the eligibility status and level of benefit of

the household.

If Yes, no. of days per year ____

Your prompt return of the requested

Total base pay earnings for past 12 mos. $______

information will be appreciated. A self-

Total overtime earnings for past 12 mos. $______

addressed return envelope is enclosed.

Probability and expected date of any pay

increase: _______________________________

Name:_____________________________

Does the employee have access to a

SS#_______________________________

retirement account?

• Yes

• No

If Yes, what amount can they get access to:

$________________

RELEASE: I hereby authorize the release

Signature of _____________________________

of the requested information.

or Authorized Representative

__________________________________

________________________________________

(Signature of Applicant)

Title: ___________________________________

Date: ___________________________

Date:___________________________________

or a copy of the executed “HOME Program

Eligibility Release Form,” which authorizes

Telephone: ______________________________

the release of the information requested, is

attached.

WARNING:

Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and

willingly making false or fraudulent statements to any department of the United States Government.

*VO EMPLOYMENT FORM*

S: C

/TBRA/F

OMMUNITY

SSISTANCE

INANCIAL

SSISTANCE

ORMS

ECTION

Verification Of Employment Form

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