Team Member Self Employed

County Department of Family and Children Services

Case #:

Date:

RE:

SSN:

Dear Sir/Madam,

The above named individual is an applicant/recipient of assistance in this county. Regulations require us to verify income for all applicants/recipients. Your company was listed by this person as a place of employment, either within the past years or at the present time. In order to complete this application/ review, it is necessary that we contact you to verify this person's employment and address.

Please complete the questions on the reverse side as fully as possible. Please sign, date and return this information within FIVE DAYS as the application/review must be completed in a timely manner.

The authorization to release information signed by the client is included on this form.

Your cooperation is appreciated.

Sincerely,

Authorization to Release Information

I hereby authorize my employer to furnish complete information about

my earnings to the County .

Signature or Mark

Date

If signed by an "X", person who witnesses the mark must signs below.

Signature of Witness

Employee Information

(a) Name and address of employee from your records:

(b) Beginning date of employment: Job title of the employee:

(c) Date of first pay Gross amount of first pay $

(d) Rate of pay: $

(e) Number of hours per week this employee works:

(f) Employee is paid weekly: bi-weekly: semi-monthly: monthly: daily:

(g) Employee receives a $ salary weekly: bi-weekly: semi-monthly: monthly:

(h) Day of the week this employee is paid: Mon. Tues. Wed. Thurs. Fri. Saturday Sunday

(i) If the employee is terminated, reason for termination/separation:

(j) Employee going to another job: Yes No If so, where?

Please complete the following for the last weeks/months. Please show the date this employee actually received the checks.

Pay Period End Date

Date received

# of Hours Worked

*Gross Earnings

Net Earnings

Tips (if applicable)

*DO NOT include advance EITC payments in Gross Earnings

Employer’s Comments

(Person completing this form must sign, date and provide his/her phone number at the bottom of this form)

(a) Do you expect a change in pay? Yes No

If yes, what change do you expect?

When do you expect this change?

(b) If the person is no longer employed, provide the date of termination/separation:

(c) Last date this employee worked:

(d) Last date this employee was paid/will be paid:

(e)Total gross amount of the last pay check for this employee (Please include vacation, severance or special pay, if applicable):

Signature and job title Phone number Date

Contact this candidate