Income Verification Form
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1Income Verification Form
Child Care Case # __________________________________
Date of Notice: _______________
Client: ___________________________________________
Reason: _______ New Employment (check stubs not received yet)
_______ Current Employment Changes (hours, pay)
_______ Eligibility (check stubs not available at this time)
** I authorize my employer to release the following information to Child Care Resource & Referral. I understand that
this information may be verified by phone by the Child Care Resource & Referral staff. Any fraudulent, false, or
misleading information given may result in loss of childcare payments, and my childcare case will be cancelled or
denied.
Client s Signature: ________________________________________________________________________________
Social Security Number: ___________________________________________________________________________
THE SECTION BELOW MUST BE COMPLETED BY THE EMPLOYER
Employee Name: ________________________________________________
Start Date: _____________________
* IF ON LEAVE .. Return Date: _______________________ Type of Leave: _____________________________
Rate of Pay Hourly: ______________________________________________________________________________
Frequency of Pay: Weekly __________ Bi-Weekly __________ Twice Monthly _________ Monthly __________
* Commission? _________ * If so, what is the monthly average? __________________________________________
* Tips? _________ * If so, what is the monthly average? ______________________________________________
Is this employee paid CASH ? (meaning that taxes are not immediately deducted, client responsible for 1099 at
year s end) _____
If hours vary , please give an example schedule with the average # of hours and days worked per week. Be sure to indicate AM or PM
Hours:
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Total:
From:
To:
Do these hours vary? _______ If so, please explain: _____________________________________________________
How many hours per week on average?: ________________ How many days per week on average?: ____________
Employer/Company Name: ________________________________________________________________________
Address: ________________________________________________________ City: _________________________
Phone: ________________________________________________________ Date: ___________________________
Signature: ___________________________________________________ Title: ____________________________
Child Care Resource & Referral
801 N Larkin Ave Suite 202
Joliet, IL 60435
815-741-4622 (phone)
815-741-1170 (fax)
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Parent category: Legal