Form Hfs 266Kca PDF Details

Filling out the HFS 266KCA form is a crucial step for employees seeking medical coverage for their family through the All Kids/FamilyCare program. This form serves as a straightforward request for an employer statement, crucial for establishing eligibility for medical coverage. It asks for basic but essential information about the employee's payment schedule, whether it's weekly, every two weeks, twice a month, or monthly, and includes details about the rate of pay. Employers are prompted to provide specifics such as the employee’s Social Security Number (optional), the period of the most recent pay, the pay date, and the gross pay, excluding any Earned Income Credit. The form emphasizes the importance of the employer's accuracy and honesty, with a section for the employer's certification that the information provided is correct, including their signature and contact details. It ends with a clear indication of how and where to return the completed form, noting that while the employer's participation is voluntary, their response or lack thereof could influence the outcome of the All Kids' action. Approved by the Forms Management Center, the HFS 266KCA form represents a vital link in the chain of securing family medical coverage, underlining the interconnected roles of employment and healthcare access.

QuestionAnswer
Form NameForm Hfs 266Kca
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other nameshfs familycare request form fill, request employer statement form, fs 266kca r 7 10 pdf, all kids statement form

Form Preview Example

How frequently is the employee paid? What is the rate of pay?

REQUEST FOR EMPLOYER STATEMENT

Employer's Name and Address:

Date:

Employee's SSN: (optional)

All Kids/FamilyCare Applicant's Name:

(employee) has applied for medical coverage for his/her family.

We need information from you so that we can determine eligibility for your employee's family. Please provide the following information and return the form to the address or fax number listed below at your earliest convenience.

Weekly

Every 2 weeks

Twice a month

Monthly

Hours worked/week?

Please provide the following information for the most recent pay received by employee.

PAY PERIOD

(Beginning and end date)

PAY DATE

(Date employee received check)

GROSS PAY

(Do not include Earned Income Credit)

I certify that the above information is correct to the best of my knowledge and belief.

Signature

Date

Title of Person Completing Form

Phone Number

Please return this form to:

Employer's completion of this form or compliance with instructions is voluntary. However, failure to do so may affect All Kids' action. Form approved by the Forms Management Center.

HFS 266KCA (R-7-10)

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2. Right after the last section is done, go to type in the applicable information in these: Beginning and end date, Date employee received check, Do not include Earned Income Credit, I certify that the above, Signature, Date, Title of Person Completing Form, Phone Number, and Please return this form to.

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