Employment Verification Form - Community Child Care Council of

Office Use Only:
CM: __________________
Family ID: _____________
Providing Services to Families, Children and Seniors
Employment Verification Form
Section 1: Employee information and Verification (To be completed and signed by EMPLOYEE. Para ser completado y firmado por el
empleado.)
Imprimir nombre: Apellido:
Primer nombre:
Dirección:
Ciudad:
Estado:
Código postal:
Teléfono:
Empleador (Business Nombre):
Días & Horas de operación :
Dirección de Negocios:
Ciudad:
Teléfono de negocio
Fax del trabajo (Si procede):
Estado:
Código Postal:
I declare that I am the person stated above and that I authorize my employer to release all information requested on this form to the 4C Council.
Declaro que soy la persona arriba indicada y que autorizo a mi empleador para liberar toda la información solicitada en este formulario para el 4C
Council.
Firma del empleado
Fecha
Section 2: Employer information and Verification (To be completed by EMPLOYER)
This business participates in The Work Number. The Employer code is: __________
Employee Information
Date of Hire:
Date of Rehire or return from Leave of Absence if applicable:
If employee works FIXED schedule, complete section A
A.
Monday
Tuesday
Total work hours per week ____________
Wednesday
Thursday
Friday
Saturday
Sunday
Start
End
If employee works VARIABLE schedule, complete section B
B.
What is the number of hours per week this employee may work:
Min: __________
Max: ___________
What is the number of days per week this employee may work:
Min: __________
Max: ___________
Earliest Start Time :________________________
Latest end time: ____________________________
Check days employee MAY work:
Monday
Tuesday
Wednesday
Thursday
Hourly Rate: _________ OR Gross Monthly Salary: ____________
Pay Frequency:
Weekly
Is there possible overtime?
Employee Receives:
Bi-Weekly
Yes
Commission
No
Friday
Saturday
Is Employee paid cash:
Semi-Monthly
Sunday
Yes
No
Monthly
If yes, is it reoccuring? _____________
Bonuses
Tips
Average Monthly Amount: __________
(If more space is needed to provide information regarding parent’s employment, see other side of form to add comments)
I declare the above statements to be true and correct to the best of my knowledge. I understand the above information pertains to the
employee’s eligibility for child care benefits and is subject to review by representatives of the State of California.
Authorized Employer Representative (Print Name)
Signature of Authorized Representative
Title
Date
150 River Oaks Parkway, Suite F-1 | San Jose, CA 95134 | P. 408.487.0747 | F. 408.321.7454| www.4C.org
Revised April 2016
Providing Services to Families, Children and Seniors
Comments:
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
For Office Use Only:
First Attempt
Name of Authorized Employer Representative:
Position:
4C Council Employee:
Phone Number:
Date/Time:
Second Attempt
Name of Authorized Employer Representative:
Position:
4C Council Employee:
Phone Number:
Date/Time:
Third Attempt
Name of Authorized Employer Representative:
Position:
4C Council Employee:
Phone Number:
Date/Time:
4C Employee to complete the following:
I, _________________________________________________, hereby attest that the employer:
Refused to provide information regarding the parent’s employment
Is non-responsive to requests for information
Provided information over the phone to the authorized 4C representative
As an authorized representative of the 4C Council, I attest to the reasonableness of the
Participant’s request for services based on the description of employment and accepted
community practice.
4C Council Employee Signature:
Date/Time:
150 River Oaks Parkway, Suite F-1 | San Jose, CA 95134 | P. 408.487.0747 | F. 408.321.7454| www.4C.org
Revised April 2016