CS-1069 (ALSO KNOWN AS ECE-015)
REV. 8/15
REFERRAL TO EMPLOYER FOR EMPLOYEE INCOME INFORMATION
To be Completed by Employee
AUTHORIZATION AND CONSENT TO RELEASE INFORMATION
I (employee’s name) _________________________________________________________, give permission to my
(Print)
employer, ___________________________________________________________________________________,
(Print the company’s /organization’s /employer’s /owner’s name.)
to release my employment/income information to the NYC Administration for Children’s Services.
Employee’s Home Address:____________________________________________________________ Apt.:______
City: ________________________ State: _____ Zip: ______________
Employee’s Signature: ________________________________________ Date signed: ______________
To be Completed by Employee’s Supervisor, Personnel or Payroll Department
Note: The Administration for Children’s Services may contact you by telephone to verify employment/income information.
The individual named above is requesting/receiving publicly funded child care services. To make a financial eligibility determination, it is necessary to verify income for the last three (3) months.
Do NOT include time and leave penalties in the “GROSS INCOME” column.
Period of Employment: Start Date: ___/____/____ End Date: ____/____/____ (leave blank if still employed)
Type of Work: ____________________________________________________________________
Regular Employment Schedule
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Gross Income: $________ Income is paid [ |
] weekly [ ] bi-weekly [ |
] semi-monthly [ ] monthly |
Gross Hourly Income: $ __________ |
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Gross Payroll Information for the Past Three (3) Months
Please list overtime, if any, in the appropriate column.
Service employees must receive a combination of tips and wages as set forth by the New York State minimum hourly wage law. If the amount earned in tips cannot be verified and/or documented, 15% of gross income will be calculated and added.
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PERIOD ENDING |
HOURS |
GROSS |
OVERTIME |
TIPS |
OTHER EARNINGS |
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WORKED |
INCOME |
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AMOUNT |
TYPE |
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Business/Employer’s Name (please print):__________________________________________________________
Business Street Address: _______________________________________________________________________
City: _______________________State: _____Zip: _____ Tel. No: ( ) ___________________________________
Federal Tax ID #: _______________________
I swear and/or affirm that all of the financial information I have given related to the employee named above is true and accurate.
Signature: _________________________________ Title: _______________________ Date Signed: ____/____/___
nyc.gov/acs
