Form Dcc-90d - Sample Of Verification Of Employment And Wages
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1DCC-90D
Sample of Verification of Employment and Wages
Form DCC-90D Verification of Employment and Wages may be used to collect data needed to
confirm the applicant’s income for determination of eligibility for the Child Care Assistance Program.
The DCC-90D Verification of Employment and Wages is used for collection of information that will be
entered into KICCS. An applicant/active client's employer completes the form and verifies the income
data by his/her signature.
ation from your records for
Jane Doe
Please provide the following inform
(Employee Name)
(SSN)
1. Employee Name and/or SSN (if different) ____________________________________________________________
2. Is this person currently employed by you? XYes
No
3. Date of most recent hiring _6/1/11____
Date first paid __7/1/11_____________
4. Hourly Pay Rate ___$10.50____ Overtime Rate ____N/A____ Anticipated Hours per Week ___30____ Day of Week
Paid__Fridays__Shift Premium _________
5. Is the employee's share of taxes deducted from gross wages? XYes
No
6. Is the employee’s hourly Pay Rate scheduled to change? XYes
No If yes, the Pay Rate will change to __$12.00
beginning on 9/2/14 and will be reflected in the check the employee will receive on 9/16/14_.
7. Are wages paid
weekly, X every two weeks
,
twice a month,
monthly,
other________________________________________?
8. List the wages that have been paid during the months of ___________________ through________________.
**Earned
**Earned
Gross
Taxes
Date
Gross
Taxes
Date
Income
Income
Hours
Hours
*Tips
Wages
*Tips
Withheld
Received
Wages
Withheld
Received
Credit
Credit
(EIC)
(EIC)
60
630.00
173.25
1. 7/1/14
6.
60
630.00
173.25
2. 7/15/14
7.
60
630.00
173.25
3. 7/29/14
8.
55
577.50
169.85
4. 8/12/14
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.
The Company
Employer/Business Name ____
_________________________________________________________
Please list name, address and telephone number of the company through which payroll is issued, if different.
Nancy Smith
859)000-0000
Name ______
_________________________________________________ Phone (
____123 Main Street_____
_Lexington_____
Address
City
State __KY______Zip ___40511________
____Nancy Smith__________________________________________
Supervisor
Signature
Title ______
_______
____8/11/14________________
Date
)______________________
Print Name _____________________________________________ Phone (______
____________________________________________
__________________________
Address
City
State _______Zip__________
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