Form Fa-053 - Verification Of Employment History
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FA-053-FF (11-17) – Page 1 of 3
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
Family Assistance Administration
VERIFICATION OF
EMPLOYMENT HISTORY
DATE
CASE NUMBER/ HEAPLUS APP ID
Local Office Return Address
(Use the DES-166 envelope)
CASE NAME (Last, First, M.I.)
•
•
For questions, call 1-855-432-7587
Fax completed form to 602-257-7031 or 1-844-680-9840
•
•
The person whose name and signature appears below, or on the attached copy of the signature page of the DES/FAA
Application, has requested your cooperation in releasing the following information. Please complete and return this form via
fax to the number written above or in the enclosed envelope within 10 days from the above date.
AUTHORIZATION TO RELEASE INFORMATION / AUTORIZACION PARA DAR INFORMACION
I hereby authorize release of any and all information requested below concerning myself and my household’s members to the
Arizona Department of Economic Security. Por la presente autorizo y doy my consentimiento para que se entregue al Arizona
Department of Economic Security toda y cualquier información que se pide a continuación acerca de mí o de los miembros
de mi hogar.
EMPLOYED HOUSEHOLD MEMBER’S NAME (Last, First, M.I.) /
EMPLOYEE’S SOCIAL SECURITY NUMBER /
NOMBRE DEL MIEMBRO EMPLEADO DEL HOGAR (Su apellido, nombre, segundo inicial)
NÚMERO SEGURO SOCIAL
EMPLOYED HOUSEHOLD MEMBER’S SIGNATURE /
DATE /
FIRMA DEL MIEMBRO EMPLEADO DEL HOGAR
FECHA
Signed release attached. A photocopy or fax of a client’s or employee’s signature shall be treated as an original signature.
New/current employers please complete all questions in Sections A, B and C. Former employers please complete Section D.
A. NEW / CURRENT EMPLOYER
DATE HIRED
ANTICIPATED DATE OF FIRST CHECK
RATE OF PAY
ANTICIPATED GROSS INCOME
$
$
Per
NUMBER HOURS WORKED PER WEEK (If hours per week vary, indicate the range possible)
From:
To:
From:
To:
NO. HOURS WORKED PER DAY (If hours vary, indicate the range possible)
Mon
Tues
Wed
Thurs
Fri
Sat
Sun
DAYS OF WEEK WORKED (Check all that apply):
Yes
No
To:
If yes, range possible amount From:
DOES THE EMPLOYEE RECEIVE TIPS OR COMMISSIONS?
Yes
No
ARE WAGES RECEIVED UNDER THE WORKFORCE INVESTMENT ACT (WIA) PROGRAM?
Travel
Lodging
Uniforms
How often?
Amount? $
EMPLOYEE REIMBURSED FOR (Check one):
Weekly
Bi-weekly
Twice monthly
Monthly
EMPLOYEE IS PAID:
Yes
No
If yes, Name of Bank
IS PAY DIRECT DEPOSITED:
DAY OF WEEK OR DATE(S) PAY PERIOD ENDS
OVERTIME RATE
OVERTIME HOURS PER WEEK
WILL OVERTIME CONTINUE?
$
Yes
No
CONTRACT (If yes, attach copy and provide the gross earnings for each month(s) and year(s) indicated on Section C on page 2):
Yes
No
Per Job (Rate) $
Hourly (Rate) $
Other
CHILD SUPPORT WITHHOLDING:
Yes
No
Amount $
How often?
EXPECTED CHANGES IN INCOME:
Yes
No
When
Type:
Increase
Decrease
Other – Reason:
WORKERS COMPENSATION (Claim pending, or claim being paid):
Yes
No
Carrier’s Name:
DOES YOUR COMPANY OFFER HEALTH INSURANCE? (If yes, continue to Section B.):
Yes
No
See page 3 for EOE/ADA/LEP/GINA disclosures
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