Dss 8113 Form PDF Details

The DSS 8113 form, issued by the Department of Social Services, plays a crucial role in ensuring that individuals applying for social services assistance provide verifiable employment information. As a standardized wage verification document, it requests detailed information from employers about an employee's work status, pay rate, employment history, and expected changes in income. Designed to streamline the process of verifying an applicant's employment details, this form requires employers to confirm whether an employee is currently working for them, the start date of employment, pay frequency, and more intricate details such as bonuses or gross pay. Additionally, it delves into whether the applicant has health insurance or accesses child care benefits through their employer, offering a comprehensive snapshot of the applicant's financial situation. By accommodating sections for both current employment status and details pertaining to termination, if applicable, the DSS 8113 ensures that the Department of Social Services has all necessary information to assess an applicant's eligibility for assistance. This document not only facilitates a smoother verification process but also underpins the commitment to maintaining integrity and accuracy in the provision of social services assistance.

QuestionAnswer
Form NameDss 8113 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other nameswage verification form pdf, wage form for food stamps, nc wage verification, wage verification form

Form Preview Example

 

 

 

WAGE VERIFICATION FORM

 

 

 

 

Department of Social Services

 

 

 

 

 

DATE: _____________________________

TO:

 

 

 

Case Name:

 

 

 

 

 

 

Case No.:

 

 

 

 

 

 

Case ID:

 

 

 

 

 

 

Dist. No.:

 

Employee Name:

 

_________________________________________

 

SSN (optional):_ _ _ _ (last four digits only)

This person has applied for social services assistance. By signing the application, permission was given to contact you to verify certain information. Please verify employment information for the

above. Return this form by

 

.

This form must be completed by the employer.

Please answer the questions for boxes that are checked.

[ ]

Is this person currently employed by you or your company? [ ] Yes

[ ] No

 

 

Beginning date of employment:

 

 

 

 

 

 

 

 

Date first check received or anticipated:

 

 

 

 

 

 

 

 

How many days did the individual work during the first pay period?

 

_____

 

 

 

How many days will the individual normally work during a pay period?

 

_____

 

 

 

Do you expect any changes in income? [ ] Yes

[ ] No If yes, explain

 

 

 

 

 

 

 

 

 

 

_____

 

[] Pay Rate: $_____________ Estimated number of hours to be worked weekly: ___________

[ ] Please complete the following information for the months of

 

 

_____

 

 

 

 

 

 

 

 

 

 

 

 

Date Pay

Number of

 

Rate of

Bonus or

Gross

Tips

EITC

 

Received

Hours

 

Pay

Vacation

Pay

 

 

 

 

Month & Day

 

 

 

Pay

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CONTINUED ON NEXT PAGE

DSS-8113 (Rev. 07/08)

Family Support & Child Welfare Services Section

2

[ ] How often is the pay received?

[ ] Daily [ ] Weekly [ ] Every 2 weeks [ ] Twice a month [ ] Monthly [ ] Other

[ ]

What day of the week is the pay received?

 

 

 

 

[ ] Sunday [ ] Monday [ ] Tuesday [ ] Wednesday [ ] Thursday [ ] Friday [

] Saturday

[ ]

Does your company help pay for child care? If yes,

 

 

 

 

How much?

 

 

 

 

 

 

How often?

 

 

 

 

 

[ ]

Does this individual have health insurance coverage? [ ] Yes

[ ]

No

If yes,

 

complete the following information:

 

 

 

Insurance company name:

Certificate number:Effective date of coverage:

Persons included in coverage:

[ ]

If the individual is no longer employed by you, complete the following information:

 

Reason for termination of employment:

 

 

 

[ ] Quit

[ ] Fired

[ ] Laid off

[ ] Other:

 

Date the employment terminated:

Date final pay received:

Amount of gross income received during the last month of employment: $

If the employee quit, what was the reason given by the employee?

Thank you for your assistance in this matter. If you have any questions regarding this

 

 

form, please contact

 

 

 

at

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EMPLOYER, PLEASE SIGN BELOW AND RETURN USING THE ENCLOSED ENVELOPE OR

 

 

 

FAX TO_________________________________________.

 

 

 

 

 

 

 

 

 

__

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Company Name

Name and Title of Person Completing Form

Date

 

 

 

 

 

 

 

 

( )

 

 

 

 

 

 

 

Company Address

 

 

 

 

Telephone Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

State

 

Zip Code

 

 

 

Distribution: Original(s) to employer

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It's straightforward to fill out the form adhering to this practical guide! This is what you want to do:

1. The 8113 form necessitates certain information to be typed in. Ensure that the following blank fields are filled out:

Step no. 1 of completing dss 8113 pdf

2. Right after finishing the last step, head on to the subsequent part and enter the essential details in all these blank fields - Is this person currently employed, Please answer the questions for, Beginning date of employment Date, Do you expect any changes in, No If yes explain, Yes, Pay Rate Estimated number of, Please complete the following, Date Pay Received, Number of, Rate of, Hours, Pay, Month Day, and Bonus or Vacation.

Stage no. 2 of filling out dss 8113 pdf

3. Completing How often is the pay received, What day of the week is the, How much How often, Does your company help pay for, Daily Weekly Every weeks, Sunday Monday Tuesday, Does this individual have health, Yes No If yes, Insurance company name Certificate, and Effective date of coverage is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

Insurance company name Certificate, Does your company help pay for, and How much How often inside dss 8113 pdf

It's easy to make a mistake when filling in the Insurance company name Certificate, so make sure to take another look prior to when you submit it.

4. To go ahead, this fourth step will require filling in a few blanks. Included in these are If the individual is no longer, Reason for termination of, Fired, Laid off, Other, Date the employment terminated, If the employee quit what was the, Company Name, Thank you for your assistance in, Name and Title of Person, and Date, which are fundamental to carrying on with this particular PDF.

Writing part 4 in dss 8113 pdf

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