Verification of Hours
-116205-565785Verification of HoursName:________________________________ Social Security Number: _____________Employer/School Name: ____________________________________________Employer/School Address: __________________________________________ (Street) City, State ZIP CodeSupervisor/Professor/Other Contact Person Name: ________________________Supervisor/Professor/Other Contact Telephone Number: _____________________Check one: FORMCHECKBOX Employed FORMCHECKBOX Attending School FORMCHECKBOX Community Service FORMCHECKBOX Workfare FORMCHECKBOX Work /Experience FORMCHECKBOX Other (list) _______________Week beginning Sunday _____________Week ending Saturday _____________(date)(date)Total Hours this week: ______Enter number of hours paid for holidays, vacation or sick leave: ___________Satisfactory Progress: The individual is attending school and making satisfactory progress. FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not attending schoolI certify that the information provided above is true and correct. I understand that Workforce Solutions may ask to verify this information. Signature of Supervisor/Professor/Other contact person REQUIREDFax to _______________ On _________________(Fax number) (Day of Week) Providing false information on this form or over the telephone for the purpose of inappropriately obtaining benefits may result in civil, criminal, or administrative penalties. ................
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