Dhs 1266 Form PDF Details

The Department of Homeland Security (DHS) has released a new form, DHS 1266. The form is used to apply for an alien worker program, and it replaces the I-485 form. The new DHS 1266 form is shorter and easier to fill out than the old I-485 form. It also includes additional questions that will help the DHS better assess an applicant's eligibility for the alien worker program. As a result, applicants are encouraged to use the new DHS 1266 form when applying for an alien worker program.

QuestionAnswer
Form NameDhs 1266 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other names1266 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

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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.

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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.

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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)

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