Fairfax County Office for Children
School Age Child Care
12011 Government Center Pkwy., Suite 936, Fairfax, VA 22035
Phone: 703-449-8989 • Fax: 703-653-1304
Employment Verification Form
To be eligible for the sliding fee scale, please provide the information requested below.
Section 1: Employee Completes This Section
Employee Name: _______________________________ Contact Number: _________________ SACC Account # _______________
I authorize my employer to release information regarding my employment, salary, and work schedule.
Employee’s Signature _______________________________________ Date ____________________________
Section 2: Employer/ Manager/ Supervisor Completes This Section
1. Employee Start Date: ____________ Average Number of Hours Worked Per Week:
2. This employee does does not receive pay stubs (check one). Pay stubs will need to be submitted along with this form.
3. Frequency of Pay: Daily Weekly Bi-Weekly Semi-Monthly Monthly
4. Rate of Pay: $ Per: Hour Day Week Month
5. Employee Receives: Tips Overtime Commissions/Bonus
Provide verification below of all earnings received within the last 60 days.
Number of Hours Worked
(including
overtime)
6. Date next pay will be issued: _______________
__________________________________ _________________________________ ______________________________
Company/Employer Name (Please Print) Name of Person Completing the Form Title
______________________________________________ ______________________ ______________________________
Employer’s Address Employer’s Phone Number Employer’s Email
I certify that this information is a true and accurate statement of the employment and income earnings of my employee.
____________________________________________________ _________________________________
Manager/Supervisor’s Signature Date
Reasonable accommodations made upon
request; call 703-449-1414 or TTY 711.
A Fairfax County, Va., Form
Updated 08/2021
