CCIS Employment Verification PDF Details

The Ccis Employment Verification Form serves as a critical tool for substantiating employment details in the context of accessing subsidized child care benefits, ensuring those in need have the support they require for their families. Employers are tasked with providing comprehensive employment information about their employees, which includes the basics such as employer identification numbers, addresses, and contact details, alongside more detailed data about the employee's role, pay, schedule, and employment status. This includes whether the individual is newly hired, their income details such as hourly rate and gross pay, and even specifics around their payment schedule and method. Detailed breakdowns of the employee’s weekly work schedule over a four-week period offer insights into their working hours, which is critical for aligning child care support appropriately. Additionally, considerations around any extended leave or temporary and seasonal employment status further enrich the dataset provided to the Early Learning Resource Center (ELRC). This verification engages employers directly in the facilitation of essential child care supports by providing a structured format to detail an employee's work-related information, crucial for determining eligibility for subsidized child care programs. The call to action for employers highlights the importance of accuracy and completeness in filling out the form, emphasizing the impact of this information on the employee's access to child care support.

QuestionAnswer
Form NameCcis Employment Verification Form
Form Length2 pages
Fillable?Yes
Fillable fields116
Avg. time to fill out23 min 46 sec
Other namesccis e ployeverification form, ccis form printable, ccis employment verification form pa, ccis form

Form Preview Example

 

 

 

 

 

Employment Verification Form

 

 

 

EMPLOYER NAME/PLACE OF EMPLOYMENT:

IMMEDIATE SUPERVISOR’S NAME:

IMMEDIATE SUPERVISOR’S TITLE:

 

 

 

 

 

 

 

 

 

I authorize the release of this information and give permission to the Early Learning Resource Center (ELRC) to verify all information contained in this form.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EMPLOYEE’S PRINTED NAME

 

 

EMPLOYEE’S SIGNATURE

 

 

DATE

 

THE FOLLOWING SECTIONS MUST BE COMPLETED BY THEIR EMPLOYER

EMPLOYER IDENTIFICATION NUMBER (EIN):

ADDRESS OF EMPLOYMENT:

EMPLOYER’S TELEPHONE NUMBER:

(______) ______ - ____________

EMPLOYEE INFORMATION

EMPLOYEE’S JOB TITLE:

Is the above-mentioned employee newly hired?

Yes

No

EMPLOYMENT START DATE:

______ / ______ / ____________

EMPLOYMENT INCOME

HOURLY RATE:

GROSS PAY:

AVERAGE DAILY TIPS:

NEXT PAY DATE:

PAY FREQUENCY:

 

 

 

$

$

$

___ / ___ / ______

Weekly

Bi-Weekly (26 pays/year)

Twice a Month (24 pays/year)

Monthly

The employee: receives paystubs does NOT receive paystubs receives pay in CASH has access to pay online via the following website:

EMPLOYMENT SCHEDULE (Please indicate the days and hours the employee works and indicate whether the hours occur during A.M. or P.M.)

NOTE: If the schedule varies, please give a 4-week sample schedule.

WEEK ONE

Dates: from:__________________

 

 

to:____________________

Mon.

from_________ a.m./p.m. to_________

a.m./p.m.

Tues.

from_________ a.m./p.m. to_________

a.m./p.m.

Wed.

from_________ a.m./p.m. to_________

a.m./p.m.

Thur.

from_________ a.m./p.m. to_________

a.m./p.m.

Fri.

from_________ a.m./p.m. to_________

a.m./p.m.

Sat.

from_________ a.m./p.m. to_________

a.m./p.m.

Sun.

from_________ a.m./p.m. to_________

a.m./p.m.

TOTAL # HOURS/WEEK: _________________________

WEEK TWO

Dates: from:__________________

 

 

to:____________________

Mon.

from_________ a.m./p.m. to_________

a.m./p.m.

Tues.

from_________ a.m./p.m. to_________

a.m./p.m.

Wed.

from_________ a.m./p.m. to_________

a.m./p.m.

Thur.

from_________ a.m./p.m. to_________

a.m./p.m.

Fri.

from_________ a.m./p.m. to_________

a.m./p.m.

Sat.

from_________ a.m./p.m. to_________

a.m./p.m.

Sun.

from_________ a.m./p.m. to_________

a.m./p.m.

TOTAL # HOURS/WEEK: _________________________

WEEK THREE

Dates: from:__________________

 

 

to:____________________

Mon.

from_________ a.m./p.m. to_________

a.m./p.m.

Tues.

from_________ a.m./p.m. to_________

a.m./p.m.

Wed.

from_________ a.m./p.m. to_________

a.m./p.m.

Thur.

from_________ a.m./p.m. to_________

a.m./p.m.

Fri.

from_________ a.m./p.m. to_________

a.m./p.m.

Sat.

from_________ a.m./p.m. to_________

a.m./p.m.

Sun.

from_________ a.m./p.m. to_________

a.m./p.m.

TOTAL # HOURS/WEEK: _________________________

WEEK FOUR

Dates: from:__________________

 

 

to:____________________

Mon.

from_________ a.m./p.m. to_________

a.m./p.m.

Tues.

from_________ a.m./p.m. to_________

a.m./p.m.

Wed.

from_________ a.m./p.m. to_________

a.m./p.m.

Thur.

from_________ a.m./p.m. to_________

a.m./p.m.

Fri.

from_________ a.m./p.m. to_________

a.m./p.m.

Sat.

from_________ a.m./p.m. to_________

a.m./p.m.

Sun.

from_________ a.m./p.m. to_________

a.m./p.m.

TOTAL # HOURS/WEEK: _________________________

Effective begin date of schedule change:

EXTENDED LEAVE

Is the employee on extended leave (maternity, disability, etc.)?

Yes

No

Effective begin date of extended leave: ___ / ___ / ______

Date returned from extended leave: ___ / ___ / ______

TEMPORARY/SEASONAL EMPLOYMENT

Is the employee considered to be a temporary hire?

Yes

No

If the employee is considered a temporary hire, what is the last date of guaranteed employment? ___ / ___ / ______

If the employee is seasonal, please give: Last day of work before break: ___ / ___ / ______

 

Expected date of return following break: ___ / ___ / ______

 

 

 

 

 

 

I understand that the information I am providing will be used to determine the above-named employee’s eligibility for

subsidized child care.

 

 

 

 

 

 

 

 

 

 

 

 

EMPLOYER’S PRINTED NAME & JOB TITLE

 

 

EMPLOYER’S SIGNATURE

 

 

DATE

 

CY 925 6/19

Employment Verification Form

Dear Employer:

One of your employees has requested assistance paying his/her child care costs. We must verify his/her employment with you. This information will help us determine if this employee is eligible for the subsidized child care program. The form must be mailed directly to the Early Learning Resource Center (ELRC).

An authorized COMPANY REPRESENTATIVE (not the employee) must complete this form.

We must have an accurate record of your employee’s work schedule and employment income. Please complete the information on the back of this page. It is very important that the hours shown are specific and defined as either A.M. or P.M. (For example, 7:30 a.m. - 3:30 p.m.). If the employee’s schedule varies, please give a 4-week sample schedule. You do not need to give a 4-week sample schedule unless the employee’s schedule varies from week to week.

Thank you for your time and assistance. If you have any questions about how to complete this form, please contact the ELRC listed below.

ELRC:

Early Learning Resource Center Region 17

PO Box 311

1430 DeKalb Street

Norristown, PA 19404-0311

(610)278-3707 or (800) 281-1116 Fax (610) 278-5161

CY 925 6/19

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To complete the document, provide the details the application will ask you to for each of the next areas:

ccis employment verification form pa empty fields to fill in

Fill in the Mon, from ampm to ampm, Mon, from ampm to ampm, Mon, from ampm to ampm, Mon, from ampm to ampm, Tues from ampm to ampm, Tues from ampm to ampm, Tues from ampm to ampm, Tues from ampm to ampm, Wed, from ampm to ampm, and Wed fields with any data that can be asked by the application.

Completing ccis employment verification form pa stage 2

You will have to give specific particulars inside the segment An authorized COMPANY, We must have an accurate record of, Thank you for your time and, and ELRC.

Finishing ccis employment verification form pa step 3

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