Acd 1069 Form PDF Details

In the realm of employment and child care benefits, accurate and timely verification of an employee's income is crucial. The Acd 1069 form, also recognized by its alternative designation, CS-1069 or ECE-015, serves a pivotal role in this process. Crafted with the purpose of facilitating communication between employers and the NYC Administration for Children’s Services, this document plays a fundamental part in determining an individual's eligibility for publicly funded childcare services. Upon its completion by the employee, it grants explicit permission for their employer to disclose essential employment and income information to the involved city administration. The form itself is meticulously structured, requiring an employee to provide personal details alongside their consent for information release. Additionally, it sets a protocol for employers, guiding them through what specific income details need to be shared, emphasizing the exclusion of time and leave penalties in gross income calculations. Understanding such nuances is vital, as it includes guidelines for handling various income types—including regular wages, overtime, and tips—to ensure that the assessment of financial eligibility for childcare services is as accurate as possible. With spaces designated for meticulous record-keeping, the form covers a significant three-month period of an employee's income history, demanding a detailed account that includes the employer's testimony to the veracity of the information provided.

QuestionAnswer
Form NameAcd 1069 Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namescs 1069 form rev 4 18, nyc administration form 1069, acs 1069 2018, acd 1069 form downloads

Form Preview Example

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

 

Hours

Sunday

Monday

Tuesday

 

Wednesday

Thursday

 

Friday

Saturday

 

 

 

 

 

 

 

 

 

 

 

 

From

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

To

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Gross Income: $________ Income is paid [

] weekly [ ] bi-weekly [

] semi-monthly [ ] monthly

Gross Hourly Income: $ __________

 

 

 

 

 

 

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.

PERIOD ENDING

HOURS

GROSS

OVERTIME

TIPS

OTHER EARNINGS

 

WORKED

INCOME

 

 

AMOUNT

TYPE

 

 

 

 

 

 

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

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

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nyc administration form 1069 gaps to fill out

You have to type in the details in the section The individual named above is, GROSS INCOME column, Period of Employment Start Date, Type of Work, Regular Employment Schedule, Hours, Sunday, Monday, Tuesday, Wednesday, Thursday Friday, Saturday, From, Gross Income Income is paid, and Gross Hourly Income.

part 2 to finishing nyc administration form 1069

You will be required certain crucial information if you would like fill in the BusinessEmployers Name please, City State Zip Tel No, Federal Tax ID, I swear andor affirm that all of, Signature Title Date Signed, and nycgovacs area.

step 3 to filling out nyc administration form 1069

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