Form 170 Employment Verification Form - Delaware Health And Social Services
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1DCIS # ___________________
DELAWARE HEALTH
VERIFICATION OF
AND SOCIAL SERVICES
EMPLOYMENT
____________________________________
DIVISION OF SOCIAL SERVICES
To: _______________________________________
Date: __________________________________________
___________________________________________
Case Head: _____________________________________
___________________________________________
Case Number: ___________________________________
___________________________________________
Employee Name: _________________________________
Date of Birth: ____________________________________
Dear Employer:
Our Division is trying to make a determination of eligibility for the above named individual. Please complete the information
checked below, so we can make our eligibility determination. The individual has signed the authorization to give information
below. Please return to our DSS address below. The Division appreciates your cooperation. If there are any questions, please
call me.
Sincerely,
DSS Office Address:
_________________________________________
________________________________________________
Social Worker, Division of Social Services
________________________________________________
Phone #: _________________ Fax #:_________________ ________________________________________________
A. NEW EMPLOYMENT
Employee Position: _______________________________ Date Employment Started: ___________________________
Date First Pay: ______________ Hours Per Pay Period: _____________ Hourly Wage: __________________________
Does the employee receive tips? Yes
No
What is the average amount of tips per pay? ________________
Weekly Every Two Weeks Twice a Month Monthly
How Often Paid: (Please Check)
B. CURRENT EMPLOYMENT- Please provide all wage information From:______ _______ To: _________________
DATE PAY PERIOD
DATE PAY
AMOUNT OF
HOURS
ENDED
RECEIVED
GROSS PAY
WORKED
C. OTHER BENEFITS
Sick/FMLA
Workman’s Compensation
Lost Wages
Disability
Vacation
Please Check
Amount of Benefits Receiving: _________________________
Employer Provides Health Insurance Yes No
Employee Paid Premium Per Pay Period: _________________
D. TERMINATED EMPLOYMENT
Date Employment Ended: _____________________ Is Re-employment Likely?_________________________________
Reason No Longer Employed:
________________________________________________________________________________________________
Company Signature/Title
Date
Phone #
Fax #
I hereby give permission for release of the above information.
____________________________________________________________
Applicant/Representative Signature
Date
Form 170 (Revised 11/2010)
Document No. 350701-97-08-15
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