Form Dss-Ea-324 - Wage Verification Form - Department Of Social Services Page 2

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Case Number____________ Section: __1__
–
: ____________________
WAGE VERIFICATION
Please Return To
Fax #________________
I AUTHORIZE THE RELEASE OF THIS INFORMATION TO THE DEPARTMENT OF SOCIAL SERVICES.
_______________________________________________________________(EMPLOYEE SIGNATURE)
Please complete all sections as indicated for _______________________________________ ___________
Employee Name
Social Security Number
1
. He/she received the following earnings for the time frame _____________ through ________________
Please report on this form using fields below or submit payroll records, computer printouts, prints of computer screens,
or copies of the pay stubs.
Date RECEIVED by Employee
___/___/___ ___/___/___ ___/___/___ ___/___/___ ___/___/___
Hours Worked
________hrs ________hrs ________hrs ________hrs ________hrs
GROSS Earnings
$_________ $_________ $_________ $_________ $_________
TIPS – list only if not in gross
$_________ $_________ $_________ $_________ $_________
Child Support Deducted
$_________ $_________ $_________ $_________ $_________
NET Earnings
$_________ $_________ $_________ $_________ $_________
2.
Employment began on ______/_____/_____ First pay received or to be received _____/_____/_____
Pay checks received on
Mon
Tues
Wed
Thurs
Fri
Sat
Sun
Paid
Weekly
Bi-Weekly
Twice a Month
Monthly
Other_________
He/she will work approximately _______________ hours per week at $_______________ per hour.
 Is this under Workforce Investment Act (WIA)?
Yes-On the Job Training
Yes-Work Experience
No
 Is this graduate assistantship or stipend?
Yes
No
 Is this job expected to last at least 120 days?
Yes
No
3.
Do you anticipate any increases or decreases in hours or pay?
Yes
No If yes, please explain:
________________________________________________________________________________________
Did the employee cause a reduction in hours?
Yes
No Were increased hours refused?
Yes
No
4
. For employment that has ended: Last date of employment was _____/_____/_____.
Last check was or will be received on ____/_____/_____ for Gross Amount $_____________.
Reason the job ended:
Quit
Laid off
Fired
Failed to show up for work
Medical leave
Maternity leave
Work was temporary
Other _______________
 Did employment end due to a layoff or temporary suspension?
Yes
No
If yes, please indicate
the date you anticipate calling the employee back to work _________/_________/_________.
 Will the employee receive any other compensation such as vacation or severance pay, 401K, retirement, etc.?
Yes
No If yes, $_________ gross amount and _____/____/___date available.
5.
Health insurance information: Name of insurance company:_________________________________
Insurance not offered or not purchased by employee
Current coverage start date ____/____/____ policy #_______________ Group #________________
Employee
Dependents (please list)__________________________________________________
Covers (please check):
Inpatient
Outpatient
Prescription
Vision Care
Dental
Other__________
Mental
Cancer
Accident
LTC
Work Comp
 If employment has ended, did insurance coverage end also?
Yes
No If yes, please list the individuals
covered:____________________________________________________________________________________
The above information was provided by:
_____________________________ _______________________
___________________________________
Signature and Title of the Individual Completing this Form
Date
_________
_____________________________________________________ ___________________ ________
Please print your name and the name of the business
Business Telephone
Fax Number

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