Subsidized Child Care Application Form - Commonwealth Of Pennsylvania Page 8
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12Employment Verification Form
Dear Employer:
One of your employees has requested assistance paying his/her child care costs. We must verify his/her employment with you.
This information will help us determine if this employee is eligible for the subsidized child care program. The form must be mailed
directly to the Child Care Information Services (CCIS) agency.
An authorized COMPANY REPRESENTATIVE (not the employee) must complete this form.
We must have an accurate record of your employee’s work schedule and employment income. Please complete the information
on the back of this page. It is very important that the hours shown are specific and defined as either A.M. or P.M. (For example,
7:30 a.m. - 3:30 p.m.). If the employee’s schedule varies, please give a 4-week sample schedule. You do not need to give a
4-week sample schedule unless the employee’s schedule varies from week to week.
Thank you for your time and assistance. If you have any questions about how to complete this form, please contact the CCIS
listed below.
CCIS:
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CY 925 8/12
CY 868 12/15
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