Case Name: Case Number: Worker Name: Worker Number: Telephone: Questions: Ask your worker.
IMPORTANT REQUEST FOR EMPLOYMENT VERIFICATION
We have received information that is employed at .
Everyone who has a job must provide proof of the job and wages, even if they are no longer working at that job. If you think this information is wrong, contact your local agency by the due date below.
Following are examples of what you can use:
The enclosed form,
Your pay stubs from the last 30 days, or
An employer statement that gives the same details as the enclosed form.
If you choose to use the enclosed form, take it to your employer and ask that s/he complete and sign this form. Once the form is completed and signed, return the form to your local agency at the address listed above.
You must return this form or one of the other types of proof listed above by the due date below. It is your responsibility to return this form or other proof of this job and wages to the local agency.
IMPORTANT NOTE: If you do not provide the required proof by the due date, your benefits will stop or your application will be denied. If you have problems getting your employer to complete and/or return the form to you or your employer asks you to pay a fee to complete the form, please contact your local agency right away.
ISCONSIN DEPARTMENT OF HEALTH SERVICES
Division of Health Care Access and Accountability
EMPLOYER VERIFICATION OF EARNINGS
MUST BE COMPLETED BY THE EMPLOYER (Instructions on the back)
EMPLOYMENT VERIFICATION OF EARNINGS INSTRUCTIONS The Department of Children and Families, the Department of Health Services, a county child support agency or a county department under § 46.215, 46.22 or 46.23, a multicounty consortium, a Wisconsin Works (W-2) agency, or a tribal governing body may request form any person in this state information it determines appropriate and necessary for determining or verifying eligibility or benefits for a recipient under any income maintenance program, W-2, Child Support enforcement or Wisconsin Shares. Unless access to the information is prohibited or restricted by law, or unless the person has good cause, as determined by the departments in accordance with federal law and regulations, for refusing to cooperate, the person shall make a good faith effort to provide the information within 7 days after receiving a request under this paragraph.
We required employment and wage information concerning the employee named on this Employer Verification of Earnings form. Complete and return the form to the employee as soon as possible so that s/he can return it by the date indicated.
Review the Federal Employment Identification Number (FEIN) listed on the form. If it is incorrect or missing, write the correct number on the form, if known.
This form will be scanned. Write clearly using blue or black ink.
Write additional comments in the comments section.
Although it is the employee’s responsibility to return this form to the local agency, in order to expedite this process, you may return this form to the address or fax number listed. If you do, inform the employee that you have returned this form.
SECTION 1 - EMPLOYMENT STATUS If the employee never worked for your company, check the "Never Employed" box. Sign, date and return the form. If the employee listed on the form is no longer an employee of your company, check the "No" box. Write in the date the employment ended. Write in the date of the employee’s last paycheck and gross amount (before any deductions) of pay for his/her final month.
SECTION 2 - EMPLOYMENT INFORMATION If the employee listed on the form is employed by your company, check the "Yes" box and complete Section 2. Write in the date the employee started working for your company and the date of the employee's first check.
Employee Type – Check the temporary or permanent box if the employee is in a position that is defined as permanent by your company.
Employee Title – Check the Manager box if the employee is a manager. Check the Other box if the employee is not in a position of management as defined by your company.
Please provide your best estimate of gross wages (before any deductions) the employee will earn for the next 30 days.
Best estimate of Weekly Hours – Please provide the hours the employee is expected to work weekly.
EMPLOYER VERIFICATION OF EARNINGS INSTRUCTIONS
Rate of Pay Per Hour - If the type of pay is regular, holiday, other shift, overtime, weekend or other type of pay, indicate the rate of pay the employee earns per hour.
Regular Scheduled Hours –Indicate the employee’s regular scheduled hours and the days worked (i.e. 8:00 a.m. to 4:30 p.m. Monday, Tuesday, Wednesday and Saturday).
Gross Pay Per Pay Period - If the employee's type of pay is salary, bonus and commissions, cash and/or tips, write in the gross amount (before any deductions) the employee earns per pay period.
Frequency of Pay - Indicate how often the employee is paid.
Every other week (i.e. every other Thursday
Twice per month (i.e. the 1st and the 15th)
Once each month
On an irregular basis
Signature - This form must be completed, signed and dated by the employer or designee. Please provide the title of the person completing the form. Also, provide a telephone number and fax number if available.