Verification Of Income And Health Insurance
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1Verification of Income and Health Insurance
{Attach address label here if available}
Complete one form for each job for every adult in the household.
Complete the top portion and give the form to your employer.
Attach copies of the paystubs for the previous month’s income.
Employee Name:_______________________________ Employee Social Security Number:_________________________
Employee Work Phone:__________________________ Employee Home Phone:__________________________________
Employer Only Write Below this Line
**********************************
*********************************
A supervisor or a human resource department representative, who is authorized to release income and insurance
information, must complete this section. Please complete the information below for the above named employee. Please
return the completed form to the employee as soon as possible or FAX to 703-653-1359. If you have any questions
regarding the completion of this form call 703-324-7315. Thank you in advance for your assistance.
es
No
Name of business:________________________________________ Is business a franchise? {circle one}
Y
Form Completed by:
________________________________________________
______________________________________________
Name of Person Completing Form
Job Title
________________________________________________
______________________
___________________
Signature
Phone Number
Date
Part I- Income Verification-Please answer all questions below:
A) Date employee was hired:______________
If no longer employed, last date employee worked:___________
Weekly
Bi-weekly
Semi-monthly
Monthly
B) How often is this employee paid? {circle one}
Full-time
Part-time
C) Employee is: {circle one}
{Please explain:________________________________}
D) How much is this employee paid per hour? $_________
Average number of hours worked weekly:____________
Yes
No
E) Does this employee receive tips? {circle one}
If yes, average tips per week: $_____________
F)
Complete the information below for the last 4 pay periods:
Pay Date: ___________________
Gross Pay:$_________________
Net Pay:$__________________
Pay Date: ___________________
Gross Pay:$_________________
Net Pay:$__________________
Pay Date: ___________________
Gross Pay:$_________________
Net Pay:$__________________
Pay Date: ___________________
Gross Pay:$_________________
Net Pay:$__________________
Part II- Health Insurance Verification- Check {
} and complete all questions below that apply:
____ No health insurance is offered to this employee, or to the family of this employee.
____ The Company offers any type of Health Reimbursement/Savings Account or money toward health care.
____ This Employee is currently receiving health insurance from the employer.
Lowest cost
____ Insurance is offered.
individual is $_________ {circle one}
paycheck
per month
per
Lowest cost
____ Insurance is offered.
individual plus one is $________ {circle one} per paycheck
per month
Lowest cost
____ Insurance is offered.
family is $_________ {circle one} per paycheck
per month
____ Open Enrollment Period is on the following date: Start:__________________
End:______________________
Please attach printed information regarding the insurance offered to this employee/family if available.
CHCN 10
Rev. 9/12
Fairfax County is committed to non-discrimination on the basis of disability in all County programs, services, and activities. For information call (703) 246-2411.
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