HTML Preview Employment Verification Request Form page number 1.
Privacy Act Statement: Information on this form is collected under the authority of the Administratively Determined (AD) Pay Plan. Information collected via this form
is covered by the Privacy Act of 1974 and Privacy Act System of Records Notice DOI-85. The primary use of this information is to start, stop, or change entitlements and
to process any voluntary or involuntary deductions on pay and leave issues. The information you furnish will be used to identify records properly associated with you,
to obtain additional information to update your record, if necessary, and to determine any present or future entitlement. Disclosure may be made only to authorized
persons according to Title 5 USC 552a and for uses described in System of Records Notices DOI-85. Submission of the information in this form is voluntary; however,
requests will not be completed without the information needed to process the request.
Revised 09/2014
NATIONAL INTERAGENCY FIRE CENTER
CASUAL PAYMENT CENTER
A SERVI CE FIRST ORGANIZATION
CASUAL PAYMENT CENTER MS 270
3833
S DEVELOPMENT AVE BOISE, ID 83705-5354
PHONE: 877-471-2262 FAX: 208-433-6405
EMPLOYMENT VERIFICATION REQUEST FORM
Check one: BIA BLM FWS NPS
NAME:
SSN:
………………………………………………………………………………………………………………………
I
would like to request my:
Year-to-Date Employment Summary for year(s) ___________
*If no year is indicated, current year will be assumed.
Last Wage and Earnings Statement
Other: _____________________________________________
I give my authorization to release this information to the following location(s):
Fax #:
Attn To:
Mailing Address:
City:
State:
Zip:
………………………………………………………………………………………………………………………
SIGNATURE: ________________________________ DATE: __________ PHONE #: _______________
APPROVING OFFICIAL / POINT OF CONTACT USE ONLY
Casual’s Name: _______________________________________ SSN: _________________________
Year-to-Date Employment Summary for year(s) _______________
Last Wage and Earnings Statement
Other: __________________________________________________________
Print AO or POC Name: _______________________________
AO or POC Signature: _______________________________ Agency Fax #: ____________________