Form Hr2181a - Fax Cover Sheet Page 2

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SR# (office use only)
CONFIRMATION OF EARNINGS
The personal information requested on this form is collected under the authority of and will be used for the purpose of administering the Employment and Assistance Act and/or the Employment and Assistance for
Persons with Disabilities Act. Disclosure of personal information is subject to the provisions of the Freedom of Information and Protection of Privacy Act. Any questions should be directed to Prevention and Loss
Management Services.
Name
CONFIRMATION OF EARNINGS OF:
In regards to the above-named person, please provide the information requested below, then return this form to :
Ministry of Social Development and Social Innovation, attention:
By fax to:
or by mail to:
TO
EMPLOYMENT INFORMATION IS REQUESTED FOR THE PERIOD OF
Employment Status
Still Employed
Laid off
Quit
Fired
Medical Leave
Other
Start Date
Employment is/was
Full time
Part Time
Seasonal
Casual
End Date
Were / are contributions made to Employment Insurance?
Yes
No
If not currently working, do you expect to employ the person again during the next 12 months?
Yes
No
Possibly
If yes, please provide details of expected
start date and terms (e.g. hours/wage)
Net Earnings:
Please enter pay dates and net earnings after deductions for income tax, EI, medical insurance, CPP, superannuation, company pension and union dues.
YEAR
PAY DATE
AMOUNT
PAY DATE
AMOUNT
PAY DATE
AMOUNT
PAY DATE
AMOUNT
$
$
$
$
JANUARY
Jan
Jan
Jan
Jan
$
$
$
$
FEBRUARY
Feb
Feb
Feb
Feb
$
$
$
$
MARCH
Mar
Mar
Mar
Mar
$
$
$
$
APRIL
Apr
Apr
Apr
Apr
$
$
$
$
MAY
May
May
May
May
$
$
$
$
JUNE
Jun
Jun
Jun
Jun
$
$
$
$
JULY
Jul
Jul
Jul
Jul
$
$
$
$
AUGUST
Aug
Aug
Aug
Aug
$
$
$
$
SEPTEMBER
Sep
Sep
Sep
Sep
$
$
$
$
OCTOBER
Oct
Oct
Oct
Oct
$
$
$
$
NOVEMBER
Nov
Nov
Nov
Nov
$
$
$
$
DECEMBER
Dec
Dec
Dec
Dec
IF YOU HAVE REASON TO BELIEVE THIS PERSON IS EMPLOYED ELSEWHERE, PLEASE PROVIDE NAME AND LOCATION/ADDRESS OF OTHER POSSIBLE EMPLOYER.
PLEASE PROVIDE YOUR NAME
NAME OF COMPANY (EMPLOYER)
SIGNATURE
DATE (YYYY MMM DD)
HR2181A (14/02/21)

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