Employment & Income Verification
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1
2Employment & Income Verification
Parent/Employee Information
(to be completed by parent/employee)
Parent’s or Guardian’s Name: ________________________________________________
last
first
middle
Address: _______________________________________________________________
street
city
zip code
phone number
I authorize my employer to release any information regarding my employment requested in this form.
I also give Kidango permission to contact my employer for any clarification regarding information on
this form.
_________________________________________
Signature of parent/guardian
Date
Employment Information
(to be completed by employer)
Company/Organization Name: _______________________ Phone Number:_____________
Address: _______________________________________________________________
street
city
zip code
Hire Date: ____________Permanent or Temporary
If temporary, _________&__________
start date
end date
Work schedule: specify schedule each day (ie: 8am-5pm)
M
T
W
Th
F
Sat
Sun
If schedule varies, circle possible days of work:
M
T
W
TH
F
SAT
SUN
Total number of hours per week: _________
Earliest work start time
and
Latest work end time
Minimum hours a day
and
Maximum hours a day
Minimum days per week
and
Maximum days per week
Salary Information
(to be completed by employer)
Employee is paid $ ______
per hour per week every 2 weeks monthly semi-monthly
(circle one)
Employee is paid by
business check
cash
personal check
money order
(circle one)
Employee is paid by commission, business check or cash and gross income received in previous month of
______________is $____________.
Employer Certification
(to be completed by employer)
I swear under penalty of perjury, that the information I have given about the above named employee
is complete and accurate to the best of my knowledge.
_________________________
___________________
_(____)_____________
Name
Title
Phone Number
___________________________________
___________________
Signature of person completing this form
Date form completed
Employer must fax or scan this completed form by ___________ to:
due date
Blanca Quiroz at fax 510-897-6909 or scan to
Rev. 11/1/16
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Parent category: Legal