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200809274 20 l!0IPJi 8 EMPLOYMENT VERIFICATION TO: Employer [company] Name & Address Phone Number Fax Number RE: Social Security Number Applicant/Tenant Name Unit # (if assigned) I hereby authorizc rclease of my employment information. Signature of Applicant/Tenant Date The individual named directly above is an applicant/tenant ofa 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. Signature of Owner's Representative Return Form To: Employee Name: Job Title: Prcsently Employed: Yes Date First Employed No Last Day of Employment Current Wages/Salary: $ per (circle only one) hourly weekly bi-weekly semi-monthly monthly yearly other Frequency of Pay: (circle only one) daily weekly bi-weekly semi-monthly monthly yearly othcr Ave # of regular hours per wk: Year-to-date earnings: $ From ----.J ----.J _ through ----.J _/__ Overtime Ratc: $ per hour Average # of overtime hours per week: Shift Differential Rate: $ per hour Average # ofshifl differcntial hours per week: Commissions, bonuses, tips, other: $ (circle only one) hourly weekly bi-weekly semi-monthly monthly ycarly other List any anticipated change in the employce's rate of pay within the next 12 months: ; Effective date: If the employee's work is seasonal or sporadic, please indicate the layotTperiod(s): Additional remarks: Employer's Signature Employer's Printed Name Date Employer [Company] Name and Address Phone # Fax # E-mail NOTE: Section 1001 of Title 18 of the U.S. Code makes it a criminal offense to make willful false statements or misrepresentations to any Department or Agency of the United States as to any matter within its jurisdiction. (Updated 11107)