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EbWLUYMN:N'1' VE1tWICA1'lUN Employer [companyl Name & Address RE: Applicantrrenant Name I hereby authorime release of my employment informsdom Signature of Applicant/Tenant 200512606 Unit # (if migned) Social Security Number Date The individual named directly above is an applicanthenant of a housing program that requires verification of income. The information provided will remain confidential and will be used solely for the purpose of determining eligibility for occupancy. Your prompt response is crucial and greatly appreciated - project Owner/Management Agent Return Form To: Employee Name: Job'Iitlex Presently Employed: Yea,,,,,_ Date First Employed No — Cast Day of Employment Cu= Wages/Salary: S per (arek only one) hourly weekly bi- weekly semi - monthly monthly Frequency of pay- (circle only one) daily weekly bi- weekly semi- monthly monthly yearly other yearly other Average # of regular hours per week: Year -to -date earnings: 3 through – --- �--� –� Ovemme Rate: S. per hour Average # of overtime hours per week: Shift Differential Rate: $� Pet hour Average # of shift dif ertntial hours per week: commissions, bonuses, tips, other: $ (circle only one) hourly weddy bi- weekly semi - monthly monthly yearly other Last any anticipated change in the employees rate of pay within the next 12 months: If the employee's work is seasonal or sporadic, please indicate the layoff period(s): Additional remarks: Employer's signature Photo s Employer's Printed Name Employe' (Company) Name and Address Fax # Effective date: Dato E -maii NOTE: Set:tion 1001 ofT:trc 18 of the U.S. Code makes it a criminal offense to make willful false statements or mismpr scntations to any D�partmect or Agency cf the :.n:t.,d at.ues as to any mat- within its jurisdiction. (updated 12104)