Form Fa-053 - Verification Of Employment History Page 3
Download a blank fillable Form Fa-053 - Verification Of Employment History in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Fa-053 - Verification Of Employment History with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3FAA-053-FF (11-17)
Page 3 of 3
CASE NAME
CASE NUMBER
EMPLOYED HOUSEHOLD MEMBER’S NAME
EMPLOYEE’S SOCIAL SECURITY NUMBER
D. FORMER EMPLOYER
EMPLOYEE TERMINATION:
Last day worked
Date final check was/will be issued
Gross amount of final wages: $
Laid Off
Fired
Quit (Specify reason):
REASON FOR TERMINATION:
Retired (Monthly benefit) $
Other:
E. BENEFITS RECEIVED
Sick Leave
Vacation Leave
Disability
Severance
BENEFITS RECEIVED:
Included in final wages
Received in one payment
Paid in installments (Include future payments)
HOW PAID?
HOW OFTEN?
Date
Gross Amount: $
Date
Gross Amount: $
Date
Gross Amount: $
Date
Gross Amount: $
Date
Gross Amount: $
Date
Gross Amount: $
Yes
No
WAS THE EMPLOYEE COVERED BY HEALTH INSURANCE THROUGH YOUR COMPANY?
Yes
No
If No, complete Section B.
HAVE BENEFITS STOPPED?
F. COMPANY INFORMATION
PRINT NAME OF PERSON COMPLETING FORM
SIGNATURE OF PERSON COMPLETING FORM
TITLE
NAME OF COMPANY
PHONE NUMBER
FAX NUMBER
DATE
USDA is an equal opportunity provider and employer.
DES is an Equal Opportunity Employer/Program • Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and
the Americans with Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of
1975, and Title II of the Genetic Information Nondiscrimination Act (GINA) of 2008; the Department prohibits discrimination in
admissions, programs, services, activities, or employment based on race, color, religion, sex, national origin, age, disability,
genetics and retaliation. The Department must make a reasonable accommodation to allow a person with a disability to take
part in a program, service or activity. If you believe that you will not be able to understand or take part in a program or activity
because of your disability, please let us know of your disability needs in advance if at all possible. To request this document
in alternative format or for further information about this policy, contact your local office; TTY/TDD Services: 7-1-1. • Free
language assistance for DES services is available upon request.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal