Fillable Form Apv04 - Employment Verification printable pdf download

EMPLOYMENT VERIFICATION

Applicant/Tenant ______________________________________ SS#___________________________________________

Housing Manager

The above-named person has applied for housing assistance. We are required to verify all information that is used in determining

this person’s eligibility or level of benefits. We ask your cooperation in providing the following information and returning it to the

Housing Authority. Your prompt return of this information will assure timely processing. Please fax back this form or return in the

enclosed self-addressed envelope. This applicant has consented to the release of information as shown below.

By my signature, I consent to the release of information requested _________________________________________

Employer Name_________________________________________________________________

EIN#______________

Employer Address: __________________________________________________________________________________

Employer Phone #________________ Employer Fax #__________________

Applicant/Tenant – DO NOT complete the information below! The PHA will contact the employer to complete.

EMPLOYER: PLEASE COMPLETE THE BOX BELOW THAT APPLIES TO THIS EMPLOYEE:

Continuing Employee or New Hire

Hire Date __________ Base Pay Rate $__________ Per Hour $__________ Per Week $__________Per Month_____

(Choose one)

Job Title_______________________________________________

Average Hours per Week at Base Pay ____________ How many weeks is employee paid per year? _____________

Overtime Pay Rate per Hour $___________ Average number of overtime hours expected in the next 12 months: ______

Total Gross earnings for the past 3 months (if applicable) $_________________________________

Is this job temporary? Yes____ No____ If yes, how long? ____________

Other compensation not included above (Specify for commissions, bonuses, tips etc…)

For _________________________ $____________________ per (hour, week, month, year) Please circle one

Employee Layoff/Termination

Dates of employment __________________ to _______________________ and gross earnings $__________________

Date of termination: _______________ Date of final paycheck: __________ Amount of final Paycheck: _____________

Do you anticipate rehiring this employee? __________ If yes, when? ______________________

Signed:

_________________________________________________

Date:

_______________________________

Print Name: _______________________________________________

Print Title: _______________________________

Telephone #:________________

Fax #: _________________

PHA Use Only

Form mailed or faxed (circle one) on ______________

No response to mail or fax

Called to confirm information on ____________________ Contact Person________________________

Time of call: _________________ Phone number called: _________________

Used another form of verification: ________ Type: _____________________________________________________

APV04 02/2010

Form Apv04 - Employment Verification