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EMPLOYMENT VERIFICATION 201109462 � � ': THfS SECTIDN T(J BE COMPT;ETED�BY TENAT�1T�t1ND,EXECT7T'�D BYMANAGENt�NT�� . , , , � �...-� _�_ ,�. �_ TO: Employer[company]Name&Address Phone Number Fax Number RE: ApplicandTenant Name Social Security Number Unit#(if assigned) I hereby authorize release of my employment information. Signature of Applicant/Tenant Date The individual named directly above is an applicandtenant of a housing program that requires veritication of income.The information provided will remain confidential and will be used solely for the purpose of determir.ing eligibility for occupancy.Your prompt response is crucial and greatly appreciated. Signature of Owner's Representative Return Form To: � . � t�THIS SEG�'IO�1,T,Q BE C�MPT.,ETED BY�MPLOY�It � � �- � � �:: �c,H - *PLEASE COMPLETE EVERY LINE—IF IT DOES NOT APPLY PLEASE WRITE N/A OR NONE* Employee Name: Job Title: Presently 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 other Ave#of regular hours per wk: Year-to-date gross eamings: $ From / / through / / Overtime Rate: $ per hour Average#of overtime hours per week: Shift Differential Rate: $ per hour Average#of shift differential hours per week: Commissions,bonuses,tips,other: $ (circle only one) hourly weekly bi-weekly semi-monthly monthly yearly other List any anticipated change in the employee's rate of pay within the next 12 months: ;Effective date: If the employee's work is seasona]or sporadic,please indicate the layoff period(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 itsjurisdiction. (Updated 12/]0)