Verification of Employment

EARLY CHILDHOOD SCHOOL READINESS PROGRAMS
VERIFICATION OF EMPLOYMENT
Date: ____________________________
***Do not alter or use white out on forms, only blue/black ink is acceptable.***
Dear Employer:
In order to determine the eligibility of ___________________________________________ for financial assistance with the School Readiness (SR) Programs,
please assist us by completing this form and returning it to your employee as soon as possible. The employee has been given fourteen (14) calendar days to
return this form to our office.
DIRECTIONS: THIS FORM MUST BE COMPLETED BY THE EMPLOYER. THE INFORMATION WILL BE USED TO DETERMINE ELIGIBILITY FOR SERVICES FOR THE
EMPLOYEE BELOW:
**Current Employer Complete Section I, II & III >
Section I – Employee Information
Name of employee:________________________________________________________ Last four of SSN:____________________
Date current employment began:__________________________________ Date first pay is expected:_______________________
Rate of Pay: $__________per hour or $___________per day or $___________per week or $________per day month
Pay Schedule: □ daily □ weekly □ biweekly □ semimonthly □ monthly
Does the employee receive tips: □ Yes
□ No
* If yes, show tips in section II
How many hours per week does the employee work? _______________________________________________________
What shift does the employee work? □ Days
□ Afternoons □ Evenings
Does the employee work weekends? □ Yes
□ No
Is the employment: □ seasonal
□ Varies Time:_____________________
Days scheduled off:____________________________________
□ temporary □ permanent -- Season From_______________To_________________
What day of the week does the employee get paid on? _______________________________________________________
Section II – Payroll Record
In the table below, list the requested information for the most recent six (6) weeks:
Pay Date
Gross Earnings
Net Pay
Number of Hours
*Amount of Tips
(if not known state amount customary
Worked
Bonus/Commissions
for job performed)
Child Support
Deductions
If number of hours or rate of pay varies in the above pay periods, please explain: ________________________________________________________
Section III – Employer Information
The information written on this form is true and accurate to the best of my knowledge. I am aware that if I have given false information intentionally, I may be subject to
prosecution for fraud.
________________________________________ __________________________________________________ _____________________________
Name of Business
Business Address
Phone Number
________________________________________ ___________________________________________________ _____________________________
Signature of Person Completing Form
Title of Person Completing Form
Date
**Former Employer Complete Section IV ONLY >
Section IV – Loss/Break of Income or Employment
Name of employee:________________________________________________________ Last four of SSN:____________________
Date Employment Ended:__________________________________ Reason:______________________________________________________________________
Loss/Break of Income or Employment Termination is:
□ permanent
□ unpaid leave
□ temporary
* if unpaid leave or temporary, when will the employee return back to work?_______________________________________
The information written on this form is true and accurate to the best of my knowledge. I am aware that if I have given false information intentionally, I may be subject to
prosecution for fraud.
________________________________________ __________________________________________________ _____________________________
Name of Business
Business Address
Phone Number
_________________________________________ ___________________________________________________ _____________________________
Signature of Person Completing Form
Title of Person Completing Form
Date
SR Office use only: Loss/Break of Employment Verified by: ___________________________________________________ Date________________ Phone____________________________
Verified with: _______________________________________________________________________________________ Position_______________________________________________
Verification Attempts: (1) Date: ________________Time:______________ CSS : ___________________ (2) Date: _______________Time:_____________ CSS : ______________________
□ SR Brandon
9325 Bay Plaza, Suite 210
Tampa, FL 33619
PH (813) 740-4713 Fax (813) 740-4722
Status Change Fax (813) 739-6042
□ SR North Tampa
9309 N. Florida Ave., Suite 104
Tampa, FL 33612
PH (813) 915-3200 Fax (813) 915-3239
RBM & Status Change Fax (813) 915-3236
□ SR Administrative office @ Net Park
5701 E. Hillsborough Ave., Suite 2301
Tampa, FL 33610
PH (813) 744-8941 ext. 254 Fax (813) 744-6753
Verification of Employment 4/23/15 – rev. 4/30/15
EARLY CHILDHOOD SCHOOL READINESS PROGRAMS
DISCLAIMER STATEMENT
According to the Office of Early Learning (OEL) Rule 6M-4.203(2) (b)
“A parent must notify the coalition, or its designee, of any change in employment, income, or family size within ten (10) calendar days”. A client that has a
loss/break of employment and reports it within the specified time frame may be able to maintain eligibility for financially assisted school readiness
services. Failure to do so will lead to the termination of your child care services. If a loss/break of employment is not reported within the specified time
frame, sanction penalties will be imposed.
CLIENT NAME: _____________________________________ LAST FOUR OF SSN:________________________
VERIFICATION OF EMPLOYMENT:
A. ( ) NEW/RE-ENTER CLIENT:
1.
2.
3.
4.
Your income must be verified before child care can be authorized.
All sections on the “Verification of Employment” form (reverse side) must be filled out by authorized personnel.
The form must be returned and information complete before child care can be authorized.
My signature below confirms I understand that in order to continue the child care services at the time of my
next recertification I must have 6-8 weeks of current check stubs/receipts if paid:
Weekly- 6 check stubs/receipts
Bi-weekly- 3 check stubs/receipts
Semi-monthly- 4 check stubs/receipts
Monthly- 2 check stubs/receipts
B. ( ) CLIENTS WHO HAVE CHANGED JOBS OR SHIFT HOURS:
1. Your income must be verified before child care can be authorized for more than 14 calendar days.
2. All sections on the “Verification of Employment “form (reverse side) must be filled out by authorized personnel.
3. The form must be returned and information complete no later than your recertification date of ________________,
or child care will be terminated.
4. My signature below confirms I understand that in order to continue the child care services at the time of my
next recertification I must have 6-8 weeks of current check stubs/receipts if paid:
Weekly- 6 check stubs/receipts
Bi-weekly- 3 check stubs/receipts
Semi-monthly- 4 check stubs/receipts
Monthly- 2 check stubs/receipts
__________________________________________________
Client Signature
_______________________
Date
VERIFICATION OF LOSS/BREAK OF INCOME OR EMPLOYMENT:
1. All sections on the “Loss/Break of Income or Employment” form (reverse side) must be filled out by
authorized personnel.
2. The form must be returned and information verified no later than your recertification date of ________________,
or child care services will be terminated.
__________________________________________________
_______________________
Client Signature
Date
SRP STAFF SIGNATURE: ______________________________________
□ SR Brandon
9325 Bay Plaza, Suite 210
Tampa, FL 33619
PH (813) 740-4713 Fax (813) 740-4722
Status Change Fax (813) 739-6042
DATE: ____________________
□ SR North Tampa
9309 N. Florida Ave., Suite 104
Tampa, FL 33612
PH (813) 915-3200 Fax (813) 915-3239
RBM & Status Change Fax (813) 915-3236
□ SR Administrative office @ Net Park
5701 E. Hillsborough Ave., Suite 2301
Tampa, FL 33610
PH (813) 744-8941 ext. 254 Fax (813) 744-6753
Verification of Employment 4/23/15 – rev. 4/30/15