Form 470-3741 Employer'S Verification Of Earnings- Owa Department Of Human Services printable pdf download

TO:

Employer

Street Address

City

State

Zip Code

RE:

Employee’s Name

SSN

Dear Employer:

Please complete the attached Employer’s Statement of Earnings for the employee named above. The employee has signed this form,

authorizing you to release the information needed. Complete these sections:

Beginning Income

Ending Employment

If you need additional space for your response, please attach a separate piece of paper.

Health Insurance Benefits

Please sign and return all copies of the form by _______________________________. We have provided a postage-paid return envelope

for your use. If you have any questions, please contact me at _____________________________________. Thank you in advance for

your prompt attention to this request.

_____________________________________ Income Maintenance Worker

✁---------------------------------------------------------------------------------------------------------------------------------------------

Iowa Department of Human Services

Worker Name

EMPLOYER’S VERIFICATION OF EARNINGS

Worker Phone No.

County

Please return all copies of this form by:

Case #

________________

I authorize my employer, former employer, or insurance carrier named below to furnish the Iowa Department of Human Services any confidential

information requested regarding my employment or insurance coverage. I forever release and discharge my employer, former employer, or insurance

carrier from any liability for divulging this information. This authorization expires 60 days after the date of my signature.

Employee Last Name

First

SSN

Employee Signature

Date

Employer Name

Address

City

State

Zip Code

BEGINNING EMPLOYMENT

HEALTH INSURANCE BENEFITS

Beginning date of employment

Date first check received

Do you offer health insurance to your employees?

Yes

If no, STOP HERE. If yes, complete the following questions:

Current rate of pay: $

_________________________________ per

Date employee is eligible to enroll: ____________________________

hour

day

week

month

year

What is cost to the employee, if any, for premiums?

Frequency of pay:

weekly

biweekly

monthly

semimonthly

other - explain __________________________

PLAN OPTION

COST

PER (check only one)

Day of week pay period ends on: _______________________________.

Paid _________ days later on __________________________________.

Employee

weekly

(day of week)

52 or

48 x yearly

Hours of work per week

Avg. hours of overtime per week

Employee/Spouse

biweekly

26 or

24 x yearly

Does employee receive tips?

Estimated tip income

Employee/Children

semimonthly

Family

Yes

monthly

Does employee receive commissions?

Estimated commission income

Dental

Other

Other option

(Explain) ___________________

Yes

(Explain)____________________________________________________

ENDING EMPLOYMENT

Last date of employment

Date final check received

Gross amount

Is this a cafeteria plan?

Yes

Is employee currently enrolled?

Yes

Reason for termination:

Are employee’s dependents currently enrolled?

Quit

Fired

Laid off

Yes

Name/Address of Insurance Company

Comments: _________________________________________________

___________________________________________________________

Is employee eligible for COBRA or other

Yes

continuation benefits?

Is job still available?

Yes

Would you rehire this person?

If no, date job was filled:

______________

Yes

PLEASE ATTACH A COPY OF THE POLICY OR BENEFITS PLAN.

! Please list the gross amount of each payroll check RECEIVED or anticipated to be received in each month beginning in _____________________

through _____________________. ANTICIPATED INCOME NEED ONLY BE AN ESTIMATE. Attach a separate page if more space needed.

Date pay period ends

Date pay received

* Gross amount

Hours worked

* Is any of the gross amount Earned Income Tax Credit

If Yes, Amount ______________________________

Yes

Employer/Representative Signature

Title

Phone

Date

470-3741 (Rev. 7/03)

Copy 1: DHS County Office

Copy 2: HIPP Unit

Copy 3: PROMISE JOBS Local Office

Copy 4: Control

Form 470-3741 Employer'S Verification Of Earnings- Owa Department Of Human Services

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