Wage Verification Form
Department
Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
To
Employee Name
First Name
Last Name
Case name
Case No
Case ID
Dist. No
Please fill out applicable ones:
Is this person currently employed by you or your company?
Yes
No, no longer employed
Reason for termination of employment
Quit
Fired
Laid off
Other
Date of Employment Terminated
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date Final Pay Received
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Amount of gross income received during the last month of employment $
Beginning Date of Employment
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of Employment
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
How many days did the individual work during the first pay period?
How many days will the individual normally work during a pay period?
Do you expect any changes in income?
Yes
No
Please explain
Pay Rate $
Estimated number of hours to be worked weekly
Please complete the following information
Rows
Date Pay Received Month & Day
Numbers of Hours
Rate of Pay
Bonus or Vacation Pay
Gross pay
Tips
EITC
1
2
3
4
5
6
7
8
9
10
How often is the pay received?
Daily
Weekly
Every 2 weeks
Twice a month
Monthly
Other
What day of the week is the pay received?
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
N/A
Does your company help pay for child care?
Yes
No
N/A
How Much?
How Often?
Does this individual have health insurance coverage?
Yes
No
N/A
Insurance company name
Certificate number
Effective date of coverage
Persons included in coverage
Company Name
Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name and Title of Person Completing Form
Title
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Submit
Should be Empty: