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.
Period Ending
Date Pay
Number of Hours Worked
Total Gross Pay
Overtime Pay
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.