|
|
|
|
|
Employment Verification Form |
|
|
|
EMPLOYER NAME/PLACE OF EMPLOYMENT: |
IMMEDIATE SUPERVISOR’S NAME: |
IMMEDIATE SUPERVISOR’S TITLE: |
|
|
|
|
|
|
|
|
|
I authorize the release of this information and give permission to the Early Learning Resource Center (ELRC) to verify all information contained in this form. |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
EMPLOYEE’S PRINTED NAME |
|
|
EMPLOYEE’S SIGNATURE |
|
|
DATE |
|
THE FOLLOWING SECTIONS MUST BE COMPLETED BY THEIR EMPLOYER
EMPLOYER IDENTIFICATION NUMBER (EIN):
EMPLOYER’S TELEPHONE NUMBER:
(______) ______ - ____________
Is the above-mentioned employee newly hired? |
Yes |
No |
EMPLOYMENT START DATE:
______ / ______ / ____________
EMPLOYMENT INCOME
HOURLY RATE: |
GROSS PAY: |
AVERAGE DAILY TIPS: |
NEXT PAY DATE: |
PAY FREQUENCY: |
|
|
|
$ |
$ |
$ |
___ / ___ / ______ |
Weekly |
Bi-Weekly (26 pays/year) |
Twice a Month (24 pays/year) |
Monthly |
The employee: receives paystubs does NOT receive paystubs receives pay in CASH has access to pay online via the following website:
EMPLOYMENT SCHEDULE (Please indicate the days and hours the employee works and indicate whether the hours occur during A.M. or P.M.)
NOTE: If the schedule varies, please give a 4-week sample schedule.
|
|
|
|
WEEK ONE |
Dates: from:__________________ |
|
|
to:____________________ |
Mon. |
from_________ a.m./p.m. to_________ |
a.m./p.m. |
Tues. |
from_________ a.m./p.m. to_________ |
a.m./p.m. |
Wed. |
from_________ a.m./p.m. to_________ |
a.m./p.m. |
Thur. |
from_________ a.m./p.m. to_________ |
a.m./p.m. |
Fri. |
from_________ a.m./p.m. to_________ |
a.m./p.m. |
Sat. |
from_________ a.m./p.m. to_________ |
a.m./p.m. |
Sun. |
from_________ a.m./p.m. to_________ |
a.m./p.m. |
TOTAL # HOURS/WEEK: _________________________
|
|
|
|
WEEK TWO |
Dates: from:__________________ |
|
|
to:____________________ |
Mon. |
from_________ a.m./p.m. to_________ |
a.m./p.m. |
Tues. |
from_________ a.m./p.m. to_________ |
a.m./p.m. |
Wed. |
from_________ a.m./p.m. to_________ |
a.m./p.m. |
Thur. |
from_________ a.m./p.m. to_________ |
a.m./p.m. |
Fri. |
from_________ a.m./p.m. to_________ |
a.m./p.m. |
Sat. |
from_________ a.m./p.m. to_________ |
a.m./p.m. |
Sun. |
from_________ a.m./p.m. to_________ |
a.m./p.m. |
TOTAL # HOURS/WEEK: _________________________
|
|
|
|
WEEK THREE |
Dates: from:__________________ |
|
|
to:____________________ |
Mon. |
from_________ a.m./p.m. to_________ |
a.m./p.m. |
Tues. |
from_________ a.m./p.m. to_________ |
a.m./p.m. |
Wed. |
from_________ a.m./p.m. to_________ |
a.m./p.m. |
Thur. |
from_________ a.m./p.m. to_________ |
a.m./p.m. |
Fri. |
from_________ a.m./p.m. to_________ |
a.m./p.m. |
Sat. |
from_________ a.m./p.m. to_________ |
a.m./p.m. |
Sun. |
from_________ a.m./p.m. to_________ |
a.m./p.m. |
TOTAL # HOURS/WEEK: _________________________
|
|
|
|
WEEK FOUR |
Dates: from:__________________ |
|
|
to:____________________ |
Mon. |
from_________ a.m./p.m. to_________ |
a.m./p.m. |
Tues. |
from_________ a.m./p.m. to_________ |
a.m./p.m. |
Wed. |
from_________ a.m./p.m. to_________ |
a.m./p.m. |
Thur. |
from_________ a.m./p.m. to_________ |
a.m./p.m. |
Fri. |
from_________ a.m./p.m. to_________ |
a.m./p.m. |
Sat. |
from_________ a.m./p.m. to_________ |
a.m./p.m. |
Sun. |
from_________ a.m./p.m. to_________ |
a.m./p.m. |
TOTAL # HOURS/WEEK: _________________________
Effective begin date of schedule change:
EXTENDED LEAVE
Is the employee on extended leave (maternity, disability, etc.)? |
Yes |
No |
Effective begin date of extended leave: ___ / ___ / ______
Date returned from extended leave: ___ / ___ / ______
TEMPORARY/SEASONAL EMPLOYMENT
Is the employee considered to be a temporary hire? |
Yes |
No |
If the employee is considered a temporary hire, what is the last date of guaranteed employment? ___ / ___ / ______
If the employee is seasonal, please give: Last day of work before break: ___ / ___ / ______ |
|
Expected date of return following break: ___ / ___ / ______ |
|
|
|
|
|
|
I understand that the information I am providing will be used to determine the above-named employee’s eligibility for |
subsidized child care. |
|
|
|
|
|
|
|
|
|
|
|
|
EMPLOYER’S PRINTED NAME & JOB TITLE |
|
|
EMPLOYER’S SIGNATURE |
|
|
DATE |
|
CY 925 6/19
Employment Verification Form
Dear Employer:
One of your employees has requested assistance paying his/her child care costs. We must verify his/her employment with you. This information will help us determine if this employee is eligible for the subsidized child care program. The form must be mailed directly to the Early Learning Resource Center (ELRC).
An authorized COMPANY REPRESENTATIVE (not the employee) must complete this form.
We must have an accurate record of your employee’s work schedule and employment income. Please complete the information on the back of this page. It is very important that the hours shown are specific and defined as either A.M. or P.M. (For example, 7:30 a.m. - 3:30 p.m.). If the employee’s schedule varies, please give a 4-week sample schedule. You do not need to give a 4-week sample schedule unless the employee’s schedule varies from week to week.
Thank you for your time and assistance. If you have any questions about how to complete this form, please contact the ELRC listed below.
ELRC:
Early Learning Resource Center Region 17
PO Box 311
1430 DeKalb Street
Norristown, PA 19404-0311
(610)278-3707 or (800) 281-1116 Fax (610) 278-5161
CY 925 6/19