Hcjfs 3050 Form PDF Details

If you're a resident of Ohio and are receiving public assistance, you may be required to complete HCJFS 3050 Form. This form is used to determine your eligibility for benefits, as well as other important information related to your case. Completing the HCJFS 3050 Form accurately is critical, so it's important that you understand what's required. In this blog post, we'll provide an overview of the HCJFS 3050 Form and explain how to complete it properly.

We have compiled some useful information regarding the hcjfs 3050 form. You'll have the rough time you will need to prepare the form as well as further details.

Form NameHcjfs 3050 Form
Form Length1 pages
Fillable fields61
Avg. time to fill out12 min 31 sec
Other nameshcjfs interim report, hcjfs, hcjfs purchase and prepare form, 07221 hcjfs

Form Preview Example

Hamilton County JFS Child Care Services Employment Verification Form

Dear Consumer: If you have been employed for more than one month, please provide one month of current pay stubs as verification of your employment. This form can be used for new employment, for clarification or if you are returning from a leave of absence. Employment verification must be signed by the employer and be no more than six weeks old.

Dear Employer: Please complete Sections A – D below so that we may determine whether this employee is eligible for child care services. Return to the address checked below. We appreciate your cooperation.

HCJFS Child Care Services, 222 E. Central Parkway, Cincinnati, OH 45202

ATTN: _______________________

Fax: (513) 946 - 1830

Section A – Employer Information

Company Name:


City/State/Zip code:


Fax Number:

Section B – Employee Information

Employee Name:





















Date of Hire:






Still Employed:










If No, Last Date of Employment:



Is this person on Leave of Absence?



Scheduled return date:












Does your company issue pay stubs?



Pay frequency:













Hourly Pay Rate:


Hours paid/week:


Does employee work overtime?

# of OT hours/week:

OT hourly rate:




















Indicate the Gross income of last 4 pay stubs:






Pay date_____________ $ ____________

Pay date_____________ $ ____________


Pay date ____________ $ ____________

Pay date_____________ $ ____________







Does the employee receive tips?


If yes, what is the weekly amount?


























Section C – Schedule Information




































Start Time




































End Time
























Hours at




































Does this employee work a split shift?


Number of days worked/week?


Are hours fixed or varied?














Section D – A signature is required and indicates the information is correct to the best of my knowledge.

Name and position (print)



Section E – I authorize release of the above information to HCJFS.

Employee Signature:


HCJFS 3050 (REV. 5-10)

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