Florida Kidcare PDF Details

Healthcare for children in Florida is facilitated significantly by the Florida KidCare program, aiming to ensure that eligible children have access to affordable, child-centered health insurance. A crucial component of this process is the Florida KidCare Employment Statement, a form designed to meticulously collect employment and income information from families applying for coverage. The form serves a dual-purpose: firstly, it allows applicants to authorize the release of their employment details relevant to determining their eligibility for the program, and secondly, it enables employers to provide essential information about the applicant's employment status, including hours worked, pay frequency, gross pay rate, and any variability in these details. Understandably, the form must be filled out accurately by both the employee and the employer and then submitted to the Florida KidCare office for the application to proceed. Optional to those who can provide recent pay stubs, this form, when necessitated, becomes a vital document in the verification process, ensuring that the determination of a family's eligibility for KidCare benefits is based on precise and current data.

QuestionAnswer
Form NameFlorida Kidcare
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesflorida kidcare form, self employment form florida kidcare, florida kidcare application pdf, florida self employment form

Form Preview Example

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

 

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filling out kidcare income verification form part 1

In the If hours or rate of pay has, Employer Statement What I have, Signature of Employer, Employers Title, Name of Employer please print, Employers Telephone Number, Name of Business, Date Completed, Business Address, and City State Zip field, put down your information.

If hours or rate of pay has, Employer Statement What I have, Signature of Employer, Employers Title, Name of Employer please print, Employers Telephone Number, Name of Business, Date Completed, Business Address, and City State Zip in kidcare income verification form

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