Hcjfs 3050 Form PDF Details

Navigating the essentials of child care services in Hamilton County can often lead a parent or guardian down a path filled with forms and documentation, among which sits the HCJFS 3050 form—a pivotal piece of paperwork designed to confirm employment and, consequently, eligibility for child care services. Primarily aimed at consumers who have secured employment for more than a month, the form requests a month's worth of current pay stubs to verify ongoing employment. Its usage spans various scenarios, such as new employment, the need for clarification, or the return from a leave of absence, making it versatile in its application. Employers are asked to fill out comprehensive sections detailing both their and the employee's information—including the nature of the employment, pay rate, and schedule—thus ensuring a thorough evaluation of the employee's qualifications for child care support. The form serves as a bridge between employers and Hamilton County JFS Child Care Services, making the process of determining eligibility for child care assistance both streamlined and efficient. By requiring a signature from the employer, the form not only validates the information provided but also cements the employer's involvement in facilitating access to necessary child care services for their employees. This collaborative effort underscores the community's commitment to supporting working families and their children.

Form NameHcjfs 3050 Form
Form Length1 pages
Fillable fields0
Avg. time to fill out15 sec
Other nameshcjfs interim report, 07221 hcjfs, 2018 irs 1915 itin identification number, 3050 employment form

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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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