Documentation Of Telephone Verification Template


Applicant/Resident: __________________________________________
Unit No. : _____________
Part I:
Oral (telephone) verifications may be used when other methods are not feasible. Describe the
reason(s) why third-party written or first hand verifications are not feasible in this instance. NOTE:
Attempts at third-party and first-hand verifications MUST be documented in the file.
Part II:
In lieu of third-party written or first hand verification, on ________________, at _____________,
I spoke with ____________________________________, ______________________________,
(Contact Person)
at _____________________________ at ____________________________________________.
(Phone Number)
(Name of Employer)
Part III:
Date Employment Began: __________________ Date Employment Ended: _________________
Employee’s Position: ______________________________________________________________
Gross Pay Before Deductions
Wage/Salary: $_____________  Hourly  Weekly  Bi-Weekly  Monthly  Annually
Gross Year-to-date Earnings: $___________ (Period Covering) From: __________ To: _________
Average number of hours worker per week: _____ Number of weeks employed each year: ______
Overtime (OT) Rate: $____________ Average number of hours worked per week: ___________
Shift Differential Rate: $__________
Average number of hours worked per week: ___________
Amount of tips, commission, bonuses, other: $____________  Weekly  Monthly  Annually
Expected change in pay: $__________________
Effective Date: __________________________
Is the employee’s work seasonal or sporadic? ________ If yes, what is the layoff period? ________
Other remarks regarding employee’s income: __________________________________________
(Signature of Owner or Authorized Representative)
(Printed Name)
(Printed Title)
Section 1001 of Title 18 of the U.S. Code makes it a criminal offense to willfully falsify a
material fact or make a false statement in any matter within the jurisdiction of a federal
Page 1 of 1
Revised November 2013


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