The Illinois Income Verification Form is a document that proves your income and is used to verify your eligibility for public assistance. The form is simple to complete and can be submitted online or by mail. Make sure you provide accurate information so the form can be processed quickly. Completing the form accurately will help ensure you receive the benefits you qualify for. We've created this guide to help walk you through the process of completing the Illinois Income Verification Form. We'll provide helpful tips and answer any questions you may have.
You'll find more information concerning the illinois income verification by checking out the table we compiled.
| Question | Answer |
|---|---|
| Form Name | Illinois Income Verification |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | illinois act for children forms income verification, wage verification form illinois, action for children wage verification form, illinois child care income verification form |
CCAP_IV.doc rev. 8/10/2006
INCOME VERIFICATION
1340 S Damen Avenue 3rd Floor CHICAGO, IL 60608 phone: (312)
Attention Client: This form must be signed by your
employer before submitting to our office.
TO BE FILLED OUT BY CLIENT:
Client’s Name: |
Case Number: |
Employee’s Name:
I authorize my employer to release the following information to Illinois Action for Children. I understand this form is for initial eligibility purposes and that I will be asked to submit additional proof of my income with my next Redetermination. I understand that Action for Children may need to verify this information or contact the employer by phone.
Employee’s Signature: |
Date: |
TO BE FILLED OUT BY EMPLOYER:
Name of business (if applicable):
Type of business or work performed:
Name of business owner or employer:
Business address:
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Business phone: ( |
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Start date of current employment: |
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The employee is paid by (check one): Cash Personal check Payroll check Other (please specify): |
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The employee is paid (check one): |
Weekly Biweekly |
Monthly |
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The employee receives a gross amount of $ |
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per pay period. (If amount varies, please give average amount.) |
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The employee’s gross hourly wage: $ |
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per hour |
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The employee receives weekly tips or commissions in this estimated amount: $ |
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per week |
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Monday |
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Tuesday |
Wednesday |
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Thursday |
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Friday |
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Saturday |
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Sunday |
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From: |
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a.m. |
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a.m. |
a.m. |
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a.m. |
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a.m. |
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a.m. |
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a.m. |
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p.m. |
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p.m. |
p.m. |
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p.m. |
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p.m. |
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p.m. |
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p.m. |
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To: |
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a.m. |
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a.m. |
a.m. |
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a.m. |
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a.m. |
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a.m. |
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a.m. |
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p.m. |
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p.m. |
p.m. |
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p.m. |
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p.m. |
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p.m. |
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p.m. |
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Please give the employee’s typical work schedule. (Circle either “a.m.” or “p.m.” in each applicable box.)
I verify that the above information is true and correct to the best of my knowledge. |
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Business Owner or Employer’s Signature: |
Date: |
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Business Owner or Employer’s SSN/FEIN: |
Phone: |
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FOR INTERNAL USE ONLY |
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T- |
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