Verification of Earnings for Employer to Complete

Verification of Earnings for Department of Human Services
Employee's First and Last Name

First NameLast Name
Employee's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I verify that the employee stated above began work on
What is the hourly rate the employee earns?
The average amount of hours worked per week is:
They will / have received their first paycheck on
Employee is paid:

Using the table below, please show the gross earnings (before taxes). Please list each paycheck

Are there any expected changes to the employee's earnings or employment status such as layoffs, raises, increased or reduced hours?
I do hereby certify that the above information is factual and correct to the best of my knowledge.
Place of Employment
Todays Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Telephone
Format: (000) 000-0000.
Address
Employer / Payroll Clerk Signature
Upload Supporting Documents (Optional):

Cancelof
Todays Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: