Verification of Loss of Employment
Former Employees Full Name
*
First Name
Last Name
Former Employees Date of Birth
*
/
Month
/
Day
Year
Date
Termination Date
*
/
Month
/
Day
Year
Date
Reason for Leaving
If the Termination was within the last 3 months Please List the Date the Last Check was Received
/
Month
/
Day
Year
Date
Gross Amount of this Last Check
Employer / Payroll Clerk / HR Printed Name
*
First Name
Last Name
Employer / Payroll Clerk / HR Signature
*
Date
*
/
Month
/
Day
Year
Date
Telephone
Format: (000) 000-0000.
Place of Employment
*
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