Acd 1069 Form – Fill Out and Use This PDF

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

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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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