DHS 1266 Form PDF Details

The DHS 1266 form is an essential document initiated by the State of Hawaii's Benefit, Employment, and Support Services Division, Department of Human Services. This form serves a pivotal role in gathering employment and payroll information for certain individuals, necessitating responses from employers regarding the employment status, earnings, and benefits of the specified person. Employers are asked to provide thorough details, including the starting and ending dates of employment, nature of the work carried out, reasons for termination, any potential for re-employment, and entitlements to pensions, among other specifics. Additionally, the form inquires about any non-traditional compensations like sick pay, vacation pay, severance pay, cash payments, commissions, and even non-financial rewards. It extends further to probe into whether the individual had applied for or received any Workmen’s Compensation or Temporary Disability Insurance claim payments. Health insurance coverage details, including the type and effective dates, are also requested, rounding out a comprehensive view of the employee's compensation and benefits scenario. This form, therefore, stands as a critical tool for the Department of Human Services, enabling it to accurately assess eligibility for services or benefits, reinforcing its commitment to maintain meticulous records for those it serves.

QuestionAnswer
Form Name DHS 1266 Form
Form Length 2 pages
Fillable? No
Fillable fields 0
Avg. time to fill out 30 sec
Other names 1266 form, hawaii employment record certification form, hi dhs 1266 fill, dhs 1266 2 03

Form Preview Example

STATE OF HAWAII

Benefit, Employment and Support Services Division

Department of Human Services

 

EMPLOYMENT RECORD AND PAYROLL CERTIFICATION FORM

TO:

 

DATE:

 

 

 

 

 

RE:

 

 

 

 

 

SSN:

 

 

BD:

 

To Whom It May Concern:

Employment and payroll record information on the above-named individual is being requested. Your immediate

attention to this matter is appreciated. Please respond by:

 

Thank You.

 

 

 

 

 

 

 

 

 

(Eligibility Worker)

 

 

 

 

 

 

 

 

(Unit Address / Telephone Number)

 

I,

 

 

 

 

 

 

, hereby give my permission for the release of information to the

 

Department of Human Services regarding my employment and earnings.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Applicant/Recipient’s Signature)

 

 

 

 

 

 

 

 

 

 

 

 

(Date)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Starting and ending dates of employment: From:

 

 

 

 

 

To:

 

 

 

 

1.

 

 

 

 

 

 

Nature of employment:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Reason for and type of termination from employment (i.e., quit, fired, laid-off):

 

 

3.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

. Last day worked:

 

 

Is there any possibility of your re-employing this individual now or anytime in the future?

 

 

4.

 

 

 

 

 

 

If YES, approximate date:

 

 

 

 

 

 

 

 

 

 

 

Is this individual entitled to a pension?

 

 

 

If YES, furnish date and amount of

 

 

5.

 

 

 

 

 

 

 

 

each payment (attach separate sheet).

 

 

 

 

 

 

 

 

 

 

Did this individual receive any sick pay, vacation pay, or severance pay upon termination?

 

 

6.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If YES, furnish date and amount of each payment (attach separate sheet).

 

Did this individual receive any cash payments or commissions other than those recorded in wage or

 

 

7.

 

 

 

 

 

 

salary pay records?

 

 

 

 

If yes, date and amount of each payment (attach separate sheet).

 

Did this individual receive compensation, gifts, rewards, or premiums in place of financial payments?

 

 

8.

 

 

 

 

 

 

If YES, please describe type of compensation and date given (attach separate sheet).

 

Did this individual apply for and receive any Workmen’s Compensation or Temporary Disability

 

 

9.

 

 

 

 

 

 

Insurance claim payments while employed by you?

 

 

 

 

 

If YES, furnish dates and

amount of each payment or give the name of the insurance carrier or other agency providing benefits:

If NO, state reasons for ineligibility.

DHS 1266 (2/03)

Distribution: Original to Employer; Copy to Case File

10. Is health insurance available?

 

 

 

YES

 

NO Was this individual covered by any health

plan(s)? If YES, Plan and No.:

 

 

 

 

 

 

. Type of coverage (i.e., basic,

drug, vision, dental):

 

 

 

 

 

Effective date:

 

Names of persons covered by plans:

 

 

 

 

 

 

 

.Termination date of health insurance plan:

11.If health insurance is not available, please state reason(s) why the employee is not eligible for service.

12. Please attach copies of payroll records for the period from:to:

or enter the information below. Please indicate if weekly, bi-weekly, semi-monthly, or monthly pay by listing all pay dates. Gross is pay by dates paid, not pay period ending dates. Continue on separate sheet, if necessary.

Mo.

& Yr..

Pay Period

Ending Date

Date Paid

Hours

Reg/OT

Hourly

Rate

Gross

Pay

Tips

Advance

EIC

Commissions

Medical

Premiums

Additional Comments:

I, the undersigned, certify that the information provided is a true and correct extract from the employment and payroll record(s), of which I have legal custody:

Employer’s Representative:

 

 

 

Job Title:

Signature:

 

 

Phone:

 

 

Date Prepared:

 

DHS 1266 (2/03)

Distribution: Original to Employer; Copy to Case File

How to Edit DHS 1266 Form Online for Free

With the online PDF tool by FormsPal, you'll be able to fill in or edit hawaii employment record certification form here. FormsPal team is ceaselessly working to expand the tool and help it become even easier for users with its extensive functions. Enjoy an ever-evolving experience today! Here's what you will need to do to begin:

Step 1: First, access the tool by clicking the "Get Form Button" above on this site.

Step 2: With our handy PDF file editor, it is possible to do more than just complete blanks. Try all of the features and make your documents seem high-quality with customized textual content added, or fine-tune the file's original content to perfection - all that comes with an ability to incorporate any type of graphics and sign it off.

Be attentive when completing this document. Make sure that every field is done properly.

1. While submitting the hawaii employment record certification form, make sure to incorporate all needed fields within its relevant section. This will help speed up the work, allowing for your information to be processed fast and properly.

Step no. 1 of submitting hawaii tax form

2. Just after performing the previous step, go on to the subsequent part and enter all required details in these blanks - Starting and ending dates of, Nature of employment, Reason for and type of, Last day worked, Is there any possibility of your, If YES approximate date, Is this individual entitled to a, If YES furnish date and amount of, each payment attach separate sheet, Did this individual receive any, If YES furnish date and amount of, Did this individual receive any, salary pay records, If yes date and amount of each, and Did this individual receive.

Writing section 2 of hawaii tax form

Always be extremely mindful when completing Is there any possibility of your and Did this individual receive, because this is where many people make errors.

3. Within this part, have a look at Did this individual apply for and, Insurance claim payments while, If YES furnish dates and, amount of each payment or give the, If NO state reasons for, and Distribution Original to Employer. All these are required to be filled out with highest focus on detail.

Completing segment 3 of hawaii tax form

4. To move onward, your next part will require filling out a couple of fields. These include Is health insurance available, YES, NO Was this individual covered by, plans If YES Plan and No, Type of coverage ie basic, drug vision dental, Effective date, Names of persons covered by plans, Termination date of health, If health insurance is not, service, Please attach copies of payroll, or enter the information below, by listing all pay dates Gross is, and separate sheet if necessary, which you'll find fundamental to going forward with this process.

hawaii tax form completion process clarified (stage 4)

5. To finish your form, the particular subsection has a few additional blanks. Filling in Additional Comments, and I the undersigned certify that the should finalize everything and you can be done in a flash!

Step # 5 for submitting hawaii tax form

Step 3: Make sure that the information is correct and then click "Done" to continue further. Sign up with us right now and instantly get hawaii employment record certification form, prepared for downloading. All changes you make are saved , allowing you to edit the document at a later point when required. At FormsPal, we aim to guarantee that your information is stored protected.