Form Dcc-90d - Verification Form Of Employment And Wages

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DCC-90D
COMMONWEALTH OF KENTUCKY
N
(R. 08/14)
Cabinet for Health and Family Services
Department for Community Based Services
Division of Child Care
Verification of Employment and Wages
Type of Action
APP
Date
REDET
CHANGE
Case Name
Case Number
)
Return to: Worker Name
Phone (
)
A
ddress
Fax (
Employer
Please provide the following information from your records for
(Employee Name)
(SSN)
1. Employee Name and/or SSN (if different) ____________________________________________________________
2. Is this person currently employed by you?
Yes
No
3. Date of most recent hiring ___________________
Date first paid ________________
_______
4. Hourly Pay Rate
Overtime Rate ________ Anticipated Hours per Week _______ Day of Week Paid_________Shift Premium _________
5. Is the employee's share of taxes deducted from gross wages?
Yes
No
6. Is the employee’s hourly Pay Rate scheduled to change?
Yes
No If yes, the Pay Rate will change to __________________ beginning on
_________________ and will be reflected in the check the employee will receive on_________________________.
7. Are wages paid
weekly,
every two weeks,
twice a month,
monthly,
other________________________________________?
8. List the wages that have been paid during the months of ___________________ through________________.
9. Employee title _________________________________
10. Employee work schedule _______ am/pm to ________ am/pm
Days worked: M T W TH F SA SU (Please circle all days worked)
**Earned
**Earned
Gross
Taxes
Date
Gross
Taxes
Date
Income
Income
Hours
Hours
*Tips
Wages
*Tips
Withheld
Received
Wages
Withheld
Received
Credit
Credit
(EIC)
(EIC)
1.
6.
2.
7.
3.
8.
4.
9.
5.
10.
*Report separately if not included in gross wages. **Report the amount of the EIC payment SEPARATELY.
Do not include EIC in gross wages.
Current Employment Status:
Fired
Quit
Leave
Other __________________________________ Date __________________
___________________________________________________________________________
Reason for loss of employment
________________________________________________________________________________________________________________________
If Leave, date of expected return __________________ Date of last check _____________________
Warning: Any person who aids another person to obtain assistance (or benefits) fraudulently is subject to penalties provided by state
and federal law, including fines, imprisonment or both.
I certify that the information contained in this form is true and correct to the best of my knowledge.
Employer/Business Name _____________________________________________________________
Please list name, address and telephone number of the company through which payroll is issued, if different.
_____)___________________
Name ________________________________________________________ Phone (
____________________________________________
__________________________
Address
City
State ________Zip ___________
Signature ______________________________________________ Title ___________________________ Date ______________________
)______________________
Print Name _____________________________________________ Phone (______
____________________________________________
__________________________
Address
City
State _______Zip__________
Cabinet for Health and Family Services
An Equal Opportunity Employer M/F/D
Web site:

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