Form Cc-024-Pdf - Employment And Wage Verification Statement

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CC-024-PDF (2-16)

ARIZONA DEPARTMENT OF ECONOMIC SECURITY

Child Care Administration

EMPLOYMENT AND WAGE VERIFICATION STATEMENT

The employee below has been requested to provide the following information to the Child Care Specialist. If you have any questions

regarding the use of this form or the information requested, please contact the Child Care Specialist. Please FAX the completed form

to the FAX number or Email address below.

EMPLOYEE’ S NAME (Last, First, M.I.)

SOC. SEC. NO.

CHILD CARE SPECIALIST

PHONE NO.

FAX NO.

OFFICE/DISTRICT EMAIL ADDRESS

I am authorizing the employer to release the information requested below.

EMPLOYEE’ S SIGNATURE

DATE

Signed release attached. A photocopy or facsimile of a client’s or employee’s signature shall be treated as an original signature.

EMPLOYER INFORMATION

EMPLOYER’ S NAME

OFFICE ADDRESS (NO., Street, City, State, ZIP)

EMPLOYEE EMPLOYMENT INFORMATION MUST BE COMPLETED BY THE EMPLOYER

NEWLY EMPLOYED / RETURNING TO WORK

HOURS

NO. HOURS WORKED PER WEEK (If hours. per week vary, indicate the average per week)

NO. OF OVERTIME HOURS ALWAYS WORKED PER WEEK

WAGES

HOURLY WAGE

HOURLY OVERTIME WAGE

DOES THE EMPLOYEE RECEIVE TIPS?

DOES THE EMPLOYEE RECEIVE COMMISSIONS?

Yes Amount (anticipated weekly amount) $

Yes Amount $

FREQUENCY PAID (Check one)

Weekly

Bi-weekly (every two weeks)

Semi-monthly (twice per month)

Other:

DATE STARTED

DATE OF FIRST CHECK

DATE OF FIRST FULL CHECK

GROSS AMOUNT OF FIRST FULL CHECK

(if applicable)

CURRENTLY EMPLOYED (MOST RECENT CHECK ISSUED)

DATE LAST CHECK RECEIVED

PAY PERIOD ENDING

ACTUAL DATE PAID

GROSS EARNINGS

HOURS

TIPS

FREQUENCY PAID (Check one)

Weekly

Bi-weekly (every two weeks)

Semi-monthly (twice per month)

Other:

IF NO LONGER EMPLOYED

LAST DATE WORKED

GROSS AMOUNT OF LAST PAYCHECK RECEIVED

DATE OF LAST PAYCHECK

TERMINATION DATE

TERMINATION REASON (Check One)

Laid-off

Quit

Fired

Other:

EMPLOYER SIGNATURE AND INFORMATION (Required)

NAME OF PERSON COMPLETING FORM (Type or print)

JOB TITLE

NAME OF COMPANY

COMPANY PHONE NO.

COMPANY FAX NO.

SIGNATURE OF PERSON COMPLETING FORM

PHONE NO.

DATE

FOR DES / CCA USE ONLY

SIGNATURE OF CCA PERSON COMPLETING FORM

DATE

TIME

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. For example, this means if necessary, the Department

must provide sign language interpreters for people who are deaf, a wheelchair accessible location, or enlarged print materials. It also means that the

Department will take any other reasonable action that allows you to take part in and understand a program or activity, including making reasonable

changes to an 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 602-542-4248 contact 602-542-4248; TTY/TDD Services: 7-1-1. • Free language assistance for DES services is available upon

request. • Ayuda gratuita con traducciones relacionadas con los servicios del DES está disponible a solicitud del cliente.