Dss 8113 Form PDF Details

Dss 8113 Form is a document that is used to report the earned income of an individual or business. The form can be used to report income from various sources, including wages, salaries, tips, bonuses, and commissions. The form must be filed with the Internal Revenue Service annually. In order to complete the form correctly, it is important to understand the requirements and instructions. This blog post will provide a detailed overview of the Dss 8113 Form so that you can file your taxes accurately.

Form NameDss 8113 Form
Form Length2 pages
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









Department of Social Services






DATE: _____________________________





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















Month & Day















































































































































DSS-8113 (Rev. 07/08)

Family Support & Child Welfare Services Section


[ ] 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

[ ]


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










































FAX TO_________________________________________.




























Company Name

Name and Title of Person Completing Form










( )








Company Address





Telephone Number



















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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