HTML Preview Employment Verification Form For Social Service page number 1.
DCIS # ___________________
Form 170 (Revised 11/2010) Document No. 350701-97-08-15
To: _______________________________________
Date: __________________________________________
___________________________________________
Case Head: _____________________________________
___________________________________________
Case Number: ___________________________________
___________________________________________
Employee Name: _________________________________
Date of Birth: ____________________________________
Dear Employer:
Our Division is trying to make a determination of eligibility for the above named individual. Please complete the information
checked below, so we can make our eligibility determination. The individual has signed the authorization to give information
below. Please return to our DSS address below. The Division appreciates your cooperation. If there are any questions, please
call me.
Sincerely, DSS Office Address:
_________________________________________ ________________________________________________
Social Worker, Division of Social Services ________________________________________________
Phone #: _________________ Fax #:_________________ ________________________________________________
A. NEW EMPLOYMENT
Employee Position: _______________________________ Date Employment Started: ___________________________
Date First Pay: ______________ Hours Per Pay Period: _____________ Hourly Wage: __________________________
Does the employee receive tips? Yes No What is the average amount of tips per pay? ________________
How Often Paid: (Please Check) Weekly Every Two Weeks Twice a Month Monthly
B. CURRENT EMPLOYMENT- Please provide all wage information From:______ _______ To: _________________
DATE PAY PERIOD
ENDED
DATE PAY
RECEIVED
AMOUNT OF
GROSS PAY
HOURS
WORKED
C. OTHER BENEFITS
Please Check Sick/FMLA Workman’s Compensation Lost Wages Disability Vacation
Amount of Benefits Receiving: _________________________
Employer Provides Health Insurance
Yes
No Employee Paid Premium Per Pay Period: _________________
D. TERMINATED EMPLOYMENT
Date Employment Ended: _____________________ Is Re-employment Likely?_________________________________
Reason No Longer Employed:
________________________________________________________________________________________________
Company Signature/Title Date Phone # Fax #
I hereby give permission for release of the above information.
____________________________________________________________
Applicant/Representative Signature Date
DELAWARE HEALTH
AND SOCIAL SERVICES
VERIFICATION OF
____________________________________ EMPLOYMENT
DIVISION OF SOCIAL SERVICES