CF-ES ****, PDF **/**** [**A-*.***, F.A.C.] Page * of 2

VERIFICATION OF EMPLOYMENT/LOSS OF INCOME

Date:

In order to determine the eligibility of for public assistance, please assist us by answering the questions below and returning this form to us by .

Case Name

Case Number/Cat/Seq.

Office Address / Phone Number:

Please complete each section which has been marked on Page 1 AND Page 2 of this form. Section I – GENERAL INFORMATION

1. Name of Employee: *Social Security Number: Address: 2. Job Title: Type of Work Performed: 3. Number of Hours Worked Per Week: Number of Days Worked Per Week: 4. A. How often is/was the employee paid? Day Week Bi-Weekly Monthly B. Rate of pay: $ per . Other Hr./Day/Wk./etc. (Explain)

5. Date current employment began: Date previously employed: 6. Does/did employee receive tips? Yes No (If yes, please show tips in Section III.) 7. Is/was employment seasonal? Yes No If yes, season begins: ends: 8. Is/was the employee covered by health insurance? Yes No If yes, name of insurance company: 9. Number of dependents covered:

10. Does/did the employee participate in any type of payroll savings plan or profit sharing? Yes No If yes, what is the balance? $ 11. Does the person perform their job duties: in their home in your home N/A Section II – LOSS OF INCOME

1. Date employment ended: 2. Reason for termination: 3. Is the loss of income Permanent or Temporary? If temporary, when do you expect the employee to return to work? 4. Date employee received final check: Gross amount: $

(Please list last 4 weeks in Section III.)

5. Will employee receive any vacation pay, retirement refund, or other? Yes No If yes, what type? Date received: Amount: $ 6. Is employee eligible for any type of benefits from your company, such as extended insurance coverage, workers’ compensation, or other? Yes No If yes:

A. Name of insurance company: B. Reason for benefits: CF-ES 2620, PDF 05/2010 Page 2 of 2

Case Name Case Number/Cat/Seq.

Section III – RECORD OF PAY RECEIVED

List the gross amounts and dates of checks or cash, which were paid for the last four weeks in the space below. Pay Period Ending Date Pay Received GROSS Earnings No. of

Regular

Hours

Worked

Rate of Pay

No. of

Overtime

Hours

Rate of Pay for

Overtime Tips $$ Earned Income

Credit (EIC)

If hours or rate of pay has varied in the above period, please state why. Section IV – EMPLOYER INFORMATION

What I have written on this form is true to the best of my knowledge. I know that if I give false information on purpose, I may be subject to prosecution for fraud. Signature of Employer Employer’s Title

Name of Business Telephone Number

Address Date Completed