Form Cf-Es 2620 - Verification Of Employment/loss Of Income
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VERIFICATION OF EMPLOYMENT/LOSS OF INCOME
Date:________________________
NOTE: Use the "tab" key to move to the next field.
___________________________________________
___________________________________________
___________________________________________
In order to determine the eligibility of ___________________________________________ for public assistance,
please assist us by answering the questions below and returning this form to us by __________________________ .
Office Address / Phone Number:
______________________________________________
Case Name
______________________________________________
Case Number/Cat/Seq.
Please complete each section which has been marked on Page 1 AND Page 2 of this form.
Section I – GENERAL INFORMATION
1. Name of Employee:________________________________________ *Social Security Number:____________________
Address:_________________________________________________________________________________________
2. Job Title:_________________________________________ Type of Work Performed:___________________________
3. Number of Hours Worked Per Week:________________ Number of Days Worked Per Week:_______________
4. A. How often is/was the employee paid?
Day
Week
Bi-Weekly
Monthly
B. Rate of pay: $___________ per ___________ .
Other ____________________________________________
(Explain)
Hr./Day/Wk./etc.
5. Date current employment began:___________________
Date previously employed:____________________________
6. Does/did employee receive tips?
Yes
No
(If yes, please show tips in Section III.)
7. Is/was employment seasonal?
Yes
No
If yes, season begins:_______________ ends:_______________
8. Is/was the employee covered by health insurance?
Yes
No
If yes, name of insurance company:____________________________________________________________________
9. Number of dependents covered:________________
10. Does/did the employee participate in any type of payroll savings plan or profit sharing?
Yes
No
If yes, what is the balance?
$____________________
11. Does the person perform their job duties:
in their home
in your home
N/A
Section II – LOSS OF INCOME
1. Date employment ended:___________________________________
2. Reason for termination:______________________________________________________________________________
3. Is the loss of income
Permanent or
Temporary?
If temporary, when do you expect the employee
to return to work? __________________________________________________________________________________
4. Date employee received final check:___________________________
Gross amount: $____________________
(Please list last 4 weeks in Section III.)
5. Will employee receive any vacation pay, retirement refund, or other?
Yes
No
If yes, what type? _____________________
Date received:___________________
Amount: $________________
6. Is employee eligible for any type of benefits from your company, such as extended insurance coverage, workers’
compensation, or other?
Yes
No
If yes:
A. Name of insurance company:_______________________________________________________________________
B. Reason for benefits:______________________________________________________________________________
CF-ES 2620, PDF 05/2010
[65A-1.205, F.A.C.]
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