Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)
Employment Verification Form
is a member of a household applying for assistance
(Name of applicant or member of applicant’s household)
or has income that affects another household’s application for assistance. To determine the household’s eligibility, we
must verify all earnings. Since this person is your employee, your assistance is needed.
I authorize the employ
er listed below to release the information on this form.
Signature of employee (appl
icant or member of applicant’s household) Date
Company/Employer Telephone No.
Address:
(Physical Address)
(City) (State)
(Zip Code)
1.
Is the person named above currently employed with your company?
Yes
No
Date Hired:
2. Hourly wage (complete only if paid hourly) $ /hour
3.
How often paid?
Daily
Weekly
Twice monthly
Monthly
4.
Is the employee usually paid commission, overtime, or tips?
Every two weeks
Yes
No
Section I. In the chart below, record the gross amount of income the person has received within the last 30 days.
Section II. In the chart below, please provide an estimate of his/her gross pay for the pay period if the employee has not
received his/her first paycheck.
Date Pay Period Ended Actual Hours
Estimated Pay
(prior to deductions)
Other Pay (e.g., tips, overtime, commission)
I understand that if I deliberately omit or give false information that this applicant and/or member of applicant’s household
can be removed from WIC, criminally prosecuted, or both. The above information may be verified by WIC officials.
Signature of person completing employer section of this form Title Date
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA)
civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and
institutions participating in or administering USDA programs are prohibited from
discriminating based on race, color, national origin, sex, disability, age, or reprisal or
retaliation for prior civil rights activity in any program or activity conducted or funded by
USDA.
Persons with disabilities who require alternative means of communication for program
information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should
contact the Agency (State or local) where they applied for benefits. Individuals who are
deaf, hard of hearing or have speech disabilities may contact USDA through the Federal
Relay Service at (800) 877-8339. Additionally, program information may be made
available in languages other than English.
To file a program complaint of discrimination, complete the USDA Program
Discrimination Complaint Form, (AD-3027) found online at:
http://www.ascr.usda.gov/complaint_filing_cust.html
, and at any USDA office, or write a
letter addressed to USDA and provide in the letter all of the information requested in the
form. To request a copy of the complaint form, call (866) 632-9992.
Submit your completed form or letter to USDA by:
1. mail: U.S. Departm
ent of Agriculture, Office of the Assistant Secretary for Civil Rights,
1400 Independence Avenue, SW, Washington, D.C. 20250-9410;
2. fax: (202) 690-7442; or
3. email: program.intake@usda.gov
.
This institution is an equal opportunity provider.
© 2015 All rights reserved. Stock no. WIC-19b Rev. 8/15
Date Pay Period Ended Actual Hours
Gross Pay (prior to
deductions)
Other Pay (e.g., tips, overtime, commission)
WIC Staff Completes the Following:
Employee Completes the Following:
Employer Completes the Following:
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