Form 470-2844 at a glance
What it is: Form 470-2844 is the Employer's Statement of Earnings, which must be completed by the employer to verify employment information.
Who signs: The employee signs on the Employee Signature line and enters the Date. The Person Completing the Form signs on the Signature of Person Completing the Form line and enters the Date.
A filled-in Form 470-2844 example: an employer completes page 1 for a new employee
How to fill out Form 470-2844, box by box
Employee and business
Enter the Employee's Name, the SSN and the Business Name.
Employee permission and signature
The employee gives the employer permission to share information about the employment and 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 the employee signed.
New employment, wages and pay frequency
Under NEW EMPLOYMENT, enter the Start date of employment and the Date first check received.
Provide your best estimate of ongoing wages: for Regular, Overtime and Weekend/Shift Differential, enter the Projected hours/week and the Rate of Pay/Hour.
Circle the Pay Frequency: Weekly, Bi-Weekly, Semi-Monthly or Monthly.
Enter Tips, if received, as $ per week, and Salary, if not paid hourly, as $ per.
More rules for Form 470-2844
Under Incentive/Bonus/Commision Pay, for a Bonus, circle one time or recurring, enter the $ per Month/Quarterly/Annually (circle one) and the month the bonus is received. If recurring, do you anticipate this bonus to be received regularly in the future? Yes or No. If yes, how often?
For Commission, enter the $ 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?
For Other, enter the $ per.
Enter the actual pay and best estimate of pay: the Pay Period End Date (XX/XX/XXXX), the Date Pay Received (XX/XX/XXXX), the Hours Worked and the Gross Pay (Before Deductions), and is this check a good indication of future earnings? 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? Yes or No.
Under ENDING EMPLOYMENT, enter the Last date of employment and the Date final check received.
Enter the 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 or Other. Was the employee working 30 hours a week or more? Yes or No.
Under LEAVE, provide information on leave: the Date leave began, and circle the pay status, Paid leave or Unpaid leave.
If unpaid leave, enter when their last check was received and the gross pay of this check.
If paid leave, enter what type (Workmans comp, short term disability, etc.). Enter the Date expected to return to work.
Under Work schedule/normal days scheduled per week (CCA), does schedule vary? Circle one: Yes, No or Other (explain).
If a varied schedule: enter the Normal number of days scheduled to work per week (best estimate), the Average Number of hours worked per shift (best estimate), the Earliest possible shift start time and the Latest possible shift end time.
If a set schedule: enter the Normal scheduled work hours (example 8 AM - 5 PM, please note if AM or PM) for Sun, Mon, Tue, Wed, Thu, Fri and Sat.
Under Pretax Deductions, list the amount of pretax deductions taken from gross pay for Health insurance premiums, Dental insurance premiums, Retirement plan, Health savings account, Flex spending account and Other.
Enter per (week/biweekly/semi-monthly/monthly) on each line.
Under Employer Information, enter the Name of Person Completing the Form (please print), the Fax Number and the Phone, and sign with the Date.
Enter Comments.
Questions??? Please contact: Worker Name, Worker Number, Phone Number, Fax Number, Toll Free Number, Mailing Address and E-mail Address.
Sources
[1] Form 470-2844 (Rev. 11/21), Employer's Statement of Earnings, Iowa Health and Human Services (the Official source link on this page).