Form Fa-053 - Verification Of Employment History Page 2
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3FAA-053-FF (11-17)
Page 2 of 3
CASE NAME
CASE NUMBER
EMPLOYED HOUSEHOLD MEMBER’S NAME
EMPLOYEE’S SOCIAL SECURITY NUMBER
B. HEALTH INSURANCE INFORMATION
Yes
No
DOES THE EMPLOYEE CURRENTLY HAVE (OR HAS HAD) HEALTH INSURANCE WITH YOUR COMPANY?
If yes, complete information below. If no, did employee decline health insurance?
Yes
No
NAME OF INSURANCE COMPANY
ADDRESS (No., Street)
CITY
STATE
ZIP CODE
From:
To:
POLICY NUMBER
POLICY DATE
LIST INSURED DEPENDENTS
RELATIONSHIP TO EMPLOYEE
C. PAYCHECKS ISSUED
Indicate each paycheck issued to the employee.
From: Month/Year
To: Month/Year
DATE
MONTH / YEAR
PAY PERIOD ENDING
GROSS EARNINGS
HOURS
TIPS
ACTUALLY PAID
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