HTML Preview Employment Verification Form For Child Care page number 1.
Employment Verification Form
(To be completed by employer)
Updated 6-13 Form CS004
Applicant’s Name: SS Number:
To: The employer of the undersigned: Case Number:
This is your authorization to release the information concerning my employment as required below. In
order to establish eligibility for child care assistance with Workforce Solutions Northeast Texas,
verification of employment hours and income is required. Please complete this form as soon as possible.
It is required before I can be determined eligible for the program. You may fax to Workforce Solutions
Northeast Texas at (903) 794-8012 or (877) 329-6772.
Your cooperation and prompt return of this information is appreciated.
__________________________________________________ _________________________
Signature of Employee Date
TO BE COMPLETED BY EMPLOYER:
Business
Name:
_______________________________________
Telephone #
__________________
Business
Address:
_________________________________________________________________________
Approx Hire Date: __________________ Job Title: ___________________________________
Circle how often the employee gets paid: |Weekly | Every Two Weeks | Twice Monthly | Monthly |
Please indicate the employee’s work Schedule (Examples: “M-F, 8 am to 5 pm” or “11 am to 7pm--
4 days on 2 days off” or “M-Sun Days Vary, 12 Midnight – 7 am”)
Enter Work Schedule: ________________________________________________________________
Does this schedule vary? Yes _____ No _______ If yes, please explain below:
PLEASE NOTE: A minimum of 25 hours per week participation in work or training is required for
eligibility for child care assistance through Workforce Solutions.
Avg. # Hours Worked per Week_________ Avg. Overtime Hours Worked per Week ___________
Hourly Rate of Pay: __________________ Hourly Rate for Overtime _______________________
Weekly Avg. of Tips Amt. of other Employment Income (such as
Earned (if applicable): _________________ commission, incentive pay) _____________________
Yearly Avg. of Bonuses Received: _____________
Comments___________________________________________________________________
MUST BE SIGNED BY EMPLOYER
________________________________ _______________________ __________________
Person Completing This Form (Please Print) Title Phone #
________________________________ _______________________
Signature Date