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