
EMPLOYER NAME/PLACE OF EMPLOYMENT: IMMEDIATE SUPERVISOR’S NAME: IMMEDIATE SUPERVISOR’S TITLE:
I authorize the release of this information and give permission to the Early Learning Resource Center (ELRC) to verify all information contained in this form.
EMPLOYEE’S PRINTED NAME EMPLOYEE’S SIGNATURE DATE
THE FOLLOWING SECTIONS MUST BE COMPLETED BY THEIR EMPLOYER
EMPLOYER IDENTIFICATION NUMBER (EIN): ADDRESS OF EMPLOYMENT: EMPLOYER’S TELEPHONE NUMBER:
(______) ______ - ____________
EMPLOYEE INFORMATION
EMPLOYEE’S JOB TITLE:
Is the above-mentioned employee newly hired? Yes No
EMPLOYMENT START DATE:
______ / ______ / ____________
EMPLOYMENT INCOME
HOURLY RATE:
$
GROSS PAY:
$
AVERAGE DAILY TIPS:
$
NEXT PAY DATE:
___ / ___ / ______
PAY FREQUENCY:
Weekly Bi-Weekly (26 pays/year) Twice a Month (24 pays/year) Monthly
The employee:
receives paystubs does NOT receive paystubs receives pay in CASH has access to pay online via the following website:
EMPLOYMENT SCHEDULE (Please indicate the days and hours the employee works and indicate whether the hours occur during A.M. or P.M.)
NOTE: If the schedule varies, please give a 4-week sample schedule.
WEEK ONE Dates: from: _________________
to: ___________________
Mon. from ________ a.m./p.m. to ________ a.m./p.m.
Tues. from ________ a.m./p.m. to ________ a.m./p.m.
Wed. from ________ a.m./p.m. to ________ a.m./p.m.
Thur. from ________ a.m./p.m. to ________ a.m./p.m.
Fri. from ________ a.m./p.m. to ________ a.m./p.m.
Sat. from ________ a.m./p.m. to ________ a.m./p.m.
Sun. from ________ a.m./p.m. to ________ a.m./p.m.
TOTAL # HOURS/WEEK: _________________________
WEEK TWO Dates: from: _________________
to: ___________________
Mon. from ________ a.m./p.m. to ________ a.m./p.m.
Tues. from ________ a.m./p.m. to ________ a.m./p.m.
Wed. from ________ a.m./p.m. to ________ a.m./p.m.
Thur. from ________ a.m./p.m. to ________ a.m./p.m.
Fri. from ________ a.m./p.m. to ________ a.m./p.m.
Sat. from ________ a.m./p.m. to ________ a.m./p.m.
Sun. from ________ a.m./p.m. to ________ a.m./p.m.
TOTAL # HOURS/WEEK: _________________________
WEEK THREE Dates: from: _________________
to: ___________________
Mon. from ________ a.m./p.m. to ________ a.m./p.m.
Tues. from ________ a.m./p.m. to ________ a.m./p.m.
Wed. from ________ a.m./p.m. to ________ a.m./p.m.
Thur. from ________ a.m./p.m. to ________ a.m./p.m.
Fri. from ________ a.m./p.m. to ________ a.m./p.m.
Sat. from ________ a.m./p.m. to ________ a.m./p.m.
Sun. from ________ a.m./p.m. to ________ a.m./p.m.
TOTAL # HOURS/WEEK: _________________________
WEEK FOUR Dates: from: _________________
to: ___________________
Mon. from ________ a.m./p.m. to ________ a.m./p.m.
Tues. from ________ a.m./p.m. to ________ a.m./p.m.
Wed. from ________ a.m./p.m. to ________ a.m./p.m.
Thur. from ________ a.m./p.m. to ________ a.m./p.m.
Fri. from ________ a.m./p.m. to ________ a.m./p.m.
Sat. from ________ a.m./p.m. to ________ a.m./p.m.
Sun. from ________ a.m./p.m. to ________ a.m./p.m.
TOTAL # HOURS/WEEK: _________________________
Effective begin date of schedule change:
EXTENDED LEAVE
Is the employee on extended leave (maternity, disability, etc.)? Yes No
Effective begin date of extended leave:
___ / ___ / ______ Date returned from extended leave: ___ / ___ / ______
TEMPORARY/SEASONAL EMPLOYMENT
Is the employee considered to be a temporary hire? Yes No
If the employee is considered a temporary hire, what is the last date of guaranteed employment?
___ / ___ / ______
If the employee is seasonal, please give: Last day of work before break: ___ / ___ / ______ Expected date of return following break: ___ / ___ / ______
I understand that the information I am providing will be used to determine the above-named employee’s eligibility for subsidized child care.
EMPLOYER’S PRINTED NAME & JOB TITLE EMPLOYER’S SIGNATURE DATE
Employment Verication Form
CY 925 6/19