FLORIDA KIDCARE
EMPLOYMENT STATEMENT
General Directions: Copy this form and have it completed by each employer that provides income to a family member on the KidCare application. If you provide recent pay stubs, you do not need this form completed.
Complete Section A and submit to employer for completion. Completed form must be returned to Florida KidCare, P O Box 591, Tallahassee, Florida, 32302-0591.
Section A – To Be Completed by Employee
Family Account Number: __________________________
I authorize the release of employment information for the purpose of determining KidCare eligibility.
Employee Signature: _________________________________ Date: ___________________
Employee Name: _____________________________ Employee SSN: __________________
(please print)
Section B – To Be Completed by Employer
Directions: This information is needed to help determine eligibility for KidCare Health Insurance. Please assist us by answering the following questions for the employee listed above, and returning this form to: Florida KidCare, PO Box 591, Tallahassee, Florida, 32302-0591.
(1) Number of Hours Worked Per Week: _______ |
Number of Days Worked Per Week: _______ |
(2) How often is the employee paid: |
_ Daily |
_ Weekly _ Bi-Weekly _ Monthly |
_ Twice Monthly |
_ Other: _______________ |
|
(explain) |
(3) Rate of gross pay: $ ___________ per _________________ |
_ Other: _______________ |
Hour/Day/Week/etc. |
(explain) |
(4)If hours or rate of pay has varied in the above period, please state why (include tip information here): ________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
(5)Employer Statement: What I have written on this form is true to the best of my knowledge. I know that if I give false information on purpose, I may be subject to prosecution for fraud.
_____________________________________ |
______________________________________ |
Signature of Employer |
Employer’s Title |
_____________________________________ |
(________) ___________________________ |
Name of Employer (please print) |
Employer’s Telephone Number |
_____________________________________ |
_____________________________________ |
Name of Business |
Date Completed |
_____________________________________ |
_____________________________________ |
Business Address |
City, State, Zip |
|
T24m |
