Verification Of Employment
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1VERIFICATION OF EMPLOYMENT
STATEMENT OF RELEASE
I authorize the release of employment verification information to the Contra Costa Child Care Council in order to
determine eligibility for child care subsidies provided by the California Department of Education, Child Development
Division. I declare under penalty of perjury that the information provided below is true and correct to the best of my
knowledge.
EMPLOYEE NAME (PRINT)
EMPLOYEE SSN OR ID #
EMPLOYEE JOB TITLE
EMPLOYEE SIGNATURE
PHONE #
DATE
COMPANY PERSONNEL/PAYROLL DEPARTMENT USE ONLY
In order to authorize child care services for the above named employee, the following information is needed immediately
and must be returned directly to the Contra Costa Child Care Council. Please note that your employee has given
permission to release his/her employment or pending employment information.
DATE EMPLOYMENT BEGAN OR WILL BEGIN: ________ / ______ / ________ OR DEPARTED OR WILL END: ________ / ______ / ________
EMPLOYEE SCHEDULE
Day of Week
Arrival Time
Departure Time
If flexible/vary, please explain:
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
IF EMPLOYEE HAS A FLEXIBLE/VARIABLE SCHEDULE: MINIMUM HOURS PER WEEK __________ MAXIMUM HOURS PER WEEK ___________
DOES THE EMPLOYEE WORK OVERTIME? NO YES: PLEASE EXPLAIN _______________________________________________________
EMPLOYEE EARNINGS
SALARY PAYMENT SCHEDULE & GROSS EARNINGS PER PAY PERIOD: (Frequency of employee’s pay period – check one)
MONTHLY $__________ TWICE A MONTH $__________
EVERY OTHER WEEK $__________
WEEKLY $__________
HOURLY $__________
DAILY $__________
YES NO
DOES THE EMPLOYEE RECEIVE PAID OVERTIME?
DOES THE EMPLOYEE RECEIVE COMMISSIONS, TIPS OR BONUSES? YES
NO
IF YES, HOW OFTEN? _____________________________________________________________________________________________________
.
I declare that the above mentioned information is true and correct to the best of my knowledge
Signature Company Representative
Federal Identification Number/Social Security #
Title
Date
Print Name
Phone No. (
)
Ext.
Name of Company/Employer
Employers hours of operation
Company Address
City
Zip Code
CHILD CARE COUNCIL USE ONLY
Document verified by ________________________________ on the date of ______________ with company/employer representative
__________________________________ Title ____________________________.
Is the information true and correct? Yes No
Comments: _____________________________________________________________________________________________________________.
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