Employment Verification



Employment VerificationDSHS MAILING ADDRESSDSHS, PO BOX 11699, TACOMA WA 98411-9905DSHS PHONE NUMBER FORMTEXT ?????DSHS FAX NUMBER888-338-7410Please use blue or black ink and print or type.CASE / CLIENT ID NUMBER FORMTEXT ?????DATE FORMTEXT ?????Section 1: To be filled out by the client/employee.I authorize my employer to release information to the Department of Social and Health Services.EMPLOYEE’S SIGNATURE FORMTEXT ?????SOCIAL SECURITY NUMBER (OPTIONAL) FORMTEXT ?????DATE FORMTEXT ?????Section 2: To be filled out by the employer.EMPLOYEE’S NAME FORMTEXT ?????EMPLOYER’S NAME FORMTEXT ?????EMPLOYEE’S JOB TITLE FORMTEXT ?????EMPLOYER’S ADDRESS FORMTEXT ?????Is this a new job? FORMCHECKBOX No FORMCHECKBOX YesDATE EMPLOYEE STARTED WORK FORMTEXT ?????DATE FIRST CHECK WAS RECEIVED FORMTEXT ?????AVERAGE HOURS PER WEEK FORMTEXT ?????RATE OF PAY OR SALARY (HOURLY, DAILY OR PIECE RATE) FORMTEXT ?????Has job ended? FORMCHECKBOX No FORMCHECKBOX YesIf yes, when: FORMTEXT ????? why: FORMTEXT ?????Pay frequency: FORMCHECKBOX Daily FORMCHECKBOX Weekly FORMCHECKBOX Every two weeks FORMCHECKBOX Two times a month FORMCHECKBOX Monthly IS THIS JOB WORK STUDY? FORMCHECKBOX Yes FORMCHECKBOX NoWHAT TYPE OF WORK STUDY? FORMCHECKBOX State FORMCHECKBOX FederalIF YES, PROVIDE VERIFICATION OF TOTAL FINANCIAL AID AWARD FORMTEXT ?????WHEN WILL YOUR POSITION END? FORMTEXT ?????Actual gross income (or attach payroll printout) for last three months:MONTH: FORMTEXT ?????$ FORMTEXT ?????MONTH: FORMTEXT ?????$ FORMTEXT ?????MONTH: FORMTEXT ?????$ FORMTEXT ?????Actual gross income for current month and anticipated gross income for next two months:CURRENT MONTH: FORMTEXT ?????$ FORMTEXT ?????MONTH: FORMTEXT ?????$ FORMTEXT ?????MONTH: FORMTEXT ?????$ FORMTEXT ?????Tips FORMCHECKBOX No FORMCHECKBOX Yes; if yes, how often and how much? FORMTEXT ?????Commissions FORMCHECKBOX No FORMCHECKBOX Yes; if yes, how often and how much? FORMTEXT ?????Bonuses FORMCHECKBOX No FORMCHECKBOX Yes; if yes, how often and how much? FORMTEXT ?????Overtime FORMCHECKBOX No FORMCHECKBOX Yes; if yes, how often and how much? FORMTEXT ?????Work schedule (include exact times when possible):MONDAY FORMTEXT ?????TUESDAY FORMTEXT ?????WEDNESDAY FORMTEXT ?????THURSDAY FORMTEXT ?????FRIDAY FORMTEXT ?????SATURDAY FORMTEXT ?????SUNDAY FORMTEXT ?????Is Health Insurance available? FORMCHECKBOX Yes FORMCHECKBOX No If yes, is employee enrolled in the health plan? FORMCHECKBOX Yes FORMCHECKBOX No When does the coverage begin? FORMTEXT ?????What is the employee’s portion of premiums? FORMTEXT ?????EMPLOYER/REPRESENTATIVE’S SIGNATURE FORMTEXT ?????DATE FORMTEXT ?????EMPLOYER/REPRESENTATIVE’S PRINTED NAME AND TITLE FORMTEXT ?????PHONE NUMBER FORMTEXT ????? ................
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