WAGE VERIFICATION FORM
Requesting Party
Name __________________________
Phone __________________________
E-Mail __________________________
Fax __________________________
Employee Consent
I, __________________________, authorize and hold harmless of any legal and financial
liability my employer to release to the requesting party listed above. I understand that this
information may be verified by phone, fax, or e-mail.
Signature ________________________ Date __________ Print ________________________
TO BE COMPLETED BY THE EMPLOYER ONLY
Employee Job Title: ________________________ Start Date: __________
On Leave? ☐ Yes ☐ No
If Yes, Type of Leave: __________________________________
If Yes, Return Date: __________
Monthly Average
Hourly Pay: $__________ Commission: __________ Tips: __________
Pay Period: ☐ Weekly ☐ Bi-Weekly ☐ Monthly Paid in Cash? ☐ Yes ☐ No
Do Hours Vary? ☐ Yes ☐ No
If Yes, Explain: _______________________________________
click to sign
signature
click to edit