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Employee Name (as shown on your records)
Employee Address (Street, City, State, ZIP Code - as shown on your records)
Is (or was) this person employed by you?
If yes, what type of job?
If no: Stop here – sign and date the bottom of this form and return it.
If yes: Answer all the questions below. If a question doesn’t apply, write “N/A
Rate of Pay
How Often Paid? Average Hrs. per Pay Period
Frequently Rarely Never
FICA or FIT withheld
Profit Sharing/Pension Plan
If yes, current value
Health insurance available?
If yes, employee is:
Name of insurance Company
Date Hired Date first check received Average hours per Week
If Employee is/was on
Leave Without Pay:
Start Date End Date
Do you expect any changes to the above
information within the next few months?
If yes, explain:
On the chart below, list all wages received by this employee during the month(s) of:
Date Pay Period Ended
Received Paycheck Actual Hours Gross Pay
(tips, commissions, bonuses) EITC Advance
* Please explain (in comments section below) when and how often tips, commissions, or bonuses are received.
If this person is no longer in your employ:
Date Separated Reason for Separation Date Final Check Received Gross Amount of Final Check
Company or Employer Address (Street, City, State, ZIP code)
This information is true and correct to the best of my knowledge and belief.
Signature – Person Verifying this Information Date
Title Area Code and Telephone No.