Employment Verification Form
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2EMPLOYMENT VERIFICATION
LDSS-3707
(Rev.4/01) FRONT
LOCAL DISTRICT NAME AND ADDRESS:
CASE NUMBER
WORKER ID
CASE NAME AND ADDRESS
DATE:
EMPLOYER’S NAME AND ADDRESS
Abstract of Section 143 of the N.Y.S. Social Services Law
Employers are required to furnish to the N.Y.S. Office of Temporary and
Disability Assistance information concerning wages, salaries, earnings or other
income of any applicant for, or recipient of public assistance or care, or any
relative legally responsible for the support of such applicant or recipient.
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Dear Sir/Madam;
We are currently reviewing the assistance case of the above named person. In order to complete our review of this
case, we need information concerning wages of_________________________, SSN___________________________,
Date of Birth ___________________, received for the period_____________________ to ______________________.
Please provide us with the information requested at your earliest convenience by completing this form and returning it.
Please include any information for periods when the employee was paid by sick time, vacation time, compensation, etc. A
copy of the employee’s pay ledger or a computer printout of the pay record is acceptable, as long as all of the requested
information is clearly presented. If this person is no longer working for you, please complete this form using his/her last
weeks’ earnings.
HEALTH
NO. OF HOURS
CHECK RELEASE DATE
PAY PERIOD
GROSS PAY
EIC*
ACTUAL HOURS
INSURANCE
SCHEDULED
EXCLUDING EIC*
WORKED
DEDUCTIONS
TO WORK
FROM
TO
NOTE: FOR THOSE WITH TIP INCOME, PLEASE INCLUDE TIPS IN THE GROSS PAY COLUMN.
*EARNED INCOME CREDIT
SIGNATURE OF ELIGIBILITY WORKER:
UNIT
TELEPHONE NO.
SEE THE REVERSE SIDE
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