Form 470 2844 PDF Details

The 470 2844 form serves as a vital document for employers, detailing an employee's earnings and providing a comprehensive overview of their compensation. This form, required in a variety of situations ranging from income verification for loans to government assistance qualification, includes sections for new employment information, such as the start date, pay rate, and type of pay including bonuses, commissions, and overtime. Employers are also tasked with giving an estimate of ongoing wages along with the provision for detailing any pretax deductions like health insurance premiums and retirement contributions. Additionally, the form allows employees to grant permission for their employer to share this information, ensuring that personal data can be shared without the fear of legal repercussions, but this permission is limited, expiring twelve months after signing. Specifically designed to cater to both the initial stages of employment and circumstances of ending employment, including final check details and reasons for job departure, it provides a clear record of employment status changes. The form also encompasses sections on leave, be it paid or unpaid, and work schedule, capturing variations in work hours and schedules to give an accurate picture of an employee's working conditions. This document not only streamlines the process of income verification but also ensures that the information provided is precise and authorized for use, making it an indispensable tool for both employers and employees alike.

QuestionAnswer
Form NameForm 470 2844
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other names Form470284409212

Form Preview Example

Employer's Statement of Earnings

Case #:

Date Sent

 

 

Due Date

Employee's Name:

SSN:

 

Business Name:

 

AOHMAJHKFIFMDJGK

 

Form may continue on to next page

ACOICDPOBIACDICK

 

ACLDBHLNAAFHOAFK

 

 

AKOGMAKMCIOGKCEK

Employee Permission: I give my employer permission to share information about my employment. I will not take legal action against them for sharing this information. This permission will stop the last day of the twelfth month after the month I signed below.

 

Employee Signature:

 

 

 

 

 

 

 

Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MUST BE COMPLETED BY EMPLOYER

 

 

 

 

 

 

 

EMPLOYER - Please complete sections below to verify employment information

 

 

 

 

 

 

NEW EMPLOYMENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Start date of employment ________/ _________/ _________

 

Date first check received ________/ _________/ _________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please provide your best estimate of ongoing wages

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Type of Pay

 

Projected hours/week

 

 

 

Rate of Pay/Hour

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Regular

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Overtime

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Weekend/Shift Differential

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pay Frequency (circle)

 

Weekly

 

Bi-Weekly

 

 

Semi-Monthly

Monthly

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Tips, if received

 

$

 

per week

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Salary, if not paid hourly

 

$

 

per

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Incentive/Bonus/Commision Pay

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Bonus

 

$

 

per Month/Quarterly/Annually (circle one)

 

 

 

 

 

Is this bonus one time or recurring? (Circle one)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

What month is bonus received? ________________

 

 

 

 

 

 

 

 

 

 

 

If recurring, do you anticipate this bonus to be received regularly

 

 

 

 

 

 

 

 

 

 

in the future?

Yes or No If yes, how often? __________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Commission

 

$

 

per

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is commission income recurring?

Yes or No

 

 

 

 

 

 

 

 

 

 

 

If recurring, do you expect commission to be received regularly in the future?

 

 

 

 

 

 

 

Yes or

No

If yes, how often? ____________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other

 

$

 

per

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Actual pay and best estimate of pay from

 

to

 

 

 

 

 

 

 

 

 

 

 

 

Pay Period End Date

 

Date Pay Received

Hours Worked

 

 

Gross Pay

 

Is this check a good

 

 

 

(XX/XX/XXXX)

 

(XX/XX/XXXX)

 

 

 

(Before Deductions)

 

indication of future

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

earnings?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

or

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

or

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

or

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

or

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

or

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

or

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

or

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

or

No

 

 

 

If you answered No to a check not being a good indication of future earnings, please explain why it is not:

 

 

 

 

 

 

 

____________________________________________________________________________________________________

 

 

 

 

 

Are tips included in the gross pay?

Yes or No or NA

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is Health Insurance available (circle one) Yes or No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

470-2844 (Rev. 11/21) W2844A

 

Case #:

Employer's Statement of EarningsDate Sent

 

Due Date

ENDING EMPLOYMENT

 

Last date of employment ________/ _________/ _________

Date final check received ________/ _________/ _________

Gross pay of final check $_____________________________

 

Does the final check include pay out of paid time off or vacation?

Yes or No

If yes, list the amount of paid time off or vacation received on the final check $________________________________________

Circle the reason job ended: Quit Fired Other ____________________________________________________________

Was the employee working 30 hours a week or more? Yes or No

LEAVE

Please provide information on leave:

Date leave began ________/ _________/ _________

Circle pay status: Paid leave or Unpaid leave

If unpaid leave, when was their last check received? ________/ _________/ _________

What was the gross pay of this check? $__________________________________________

If paid leave, what type? (ie. Workmans comp, short term disability, etc.) __________________________________________

Date expected to return to work ________/ _________/ _________

Work schedule/normal days scheduled per week (CCA)

Does schedule vary? (circle one) Yes No Other (explain) ________________________________________________________

If a varied schedule: Normal number of days scheduled to work per week (best estimate) _______________________________

Average Number of hours worked per shift (best estimate) ________________________________________

Earliest possible shift start time _____________ Latest possible shift end time _______________________

If a set schedule: Normal scheduled work hours (example 8 AM - 5 PM, please note if AM or PM):

___________

___________

___________ ___________

___________

___________

___________

Sun

Mon

Tue

Wed

Thu

 

Fri

Sat

Pretax Deductions

 

 

 

 

 

 

 

Please list the amount of pretax deductions taken from gross pay for:

 

 

 

 

Health insurance premiums $ ________________________

per ______________

(week/biweekly/semi-monthly/monthly)

Dental insurance premiums $ ________________________

per ______________

(week/biweekly/semi-monthly/monthly)

Retirement plan $ __________________________________

per ______________

(week/biweekly/semi-monthly/monthly)

Health savings account $ ____________________________

per ______________

(week/biweekly/semi-monthly/monthly)

Flex spending account $ _____________________________

per ______________

(week/biweekly/semi-monthly/monthly)

Other ___________________________________________

per ______________

(week/biweekly/semi-monthly/monthly)

Employer Information

Name of Person Completing the Form (please print)

Signature of Person Completing the Form

Fax Number

Phone

Date

Comments:

Worker Name

Questions??? Please contact:

Worker Number

Phone Number

Fax Number

Toll Free Number

Mailing Address

E-mail Address

470-2844 (Rev. 11/21) W2844B

How to Edit Form 470 2844 Online for Free

In case you want to fill out Form 470 2844, there's no need to install any sort of applications - simply give a try to our online PDF editor. The tool is constantly upgraded by us, acquiring new functions and growing to be more convenient. To get started on your journey, consider these simple steps:

Step 1: Click on the "Get Form" button in the top section of this page to open our PDF editor.

Step 2: After you start the editor, you'll notice the document made ready to be filled in. Besides filling out various blanks, you could also perform some other things with the form, specifically putting on custom textual content, editing the original text, inserting illustrations or photos, putting your signature on the form, and more.

It is straightforward to finish the pdf using out practical guide! Here's what you want to do:

1. Start completing your Form 470 2844 with a number of essential blank fields. Consider all of the required information and be sure there is nothing left out!

Step number 1 in completing Form 470 2844

2. Once your current task is complete, take the next step – fill out all of these fields - Regular Overtime WeekendShift, Weekly, Tips if received Salary if not, SemiMonthly, Monthly, BiWeekly, per week per, per MonthQuarterlyAnnually circle, Commission, Other, Actual pay and best estimate of, What month is bonus received If, per Is commission income, per, and Pay Period End Date with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

Step no. 2 of completing Form 470 2844

Be really mindful when filling out SemiMonthly and Other, because this is where a lot of people make errors.

3. Within this step, examine earnings Yes or No Yes or No Yes, If you answered No to a check not, and Rev WA. Each one of these should be completed with greatest accuracy.

Writing section 3 of Form 470 2844

4. This next section requires some additional information. Ensure you complete all the necessary fields - Employers Statement of Earnings, Case, Date Sent, Due Date, ENDING EMPLOYMENT Last date of, and LEAVE Please provide information - to proceed further in your process!

ENDING EMPLOYMENT Last date of, Employers Statement of Earnings, and LEAVE Please provide information in Form 470 2844

5. As a final point, this last part is precisely what you need to wrap up prior to closing the document. The fields at issue include the next: LEAVE Please provide information, Average Number of hours worked per, Earliest possible shift start time, Latest possible shift end time, If a set schedule Normal scheduled, Sun, Mon, Tue, Wed, Thu, Fri, Sat, Pretax Deductions Please list the, Dental insurance premiums, and per per.

How one can fill out Form 470 2844 step 5

Step 3: Right after you've reviewed the details in the fields, click "Done" to conclude your document generation. Right after getting a7-day free trial account here, it will be possible to download Form 470 2844 or email it without delay. The PDF will also be available via your personal account with your each edit. FormsPal offers protected document tools devoid of personal data record-keeping or distributing. Feel safe knowing that your data is safe here!