Illinois Income Verification – Fill Out and Use This PDF

Updated: Nov 11, 2026

The Illinois Income Verification form is a crucial document utilized to confirm an individual's earnings, primarily for purposes related to Illinois Action for Children's programs. This form requires detailed income information and employer validation to assess eligibility for various services. For those in need of verifying their income through this standardized process, a simple click on the button below will guide you through filling out the form accurately.

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Illinois Income Verification PDF Details

In the heart of Illinois, particularly in bustling Chicago, the Illinois Income Verification form emerges as a crucial document for countless residents. Located at 1340 S Damen Avenue, this document is an essential tool for individuals applying for or receiving benefits through Illinois Action for Children, a program dedicated to supporting the welfare of children and families. The process starts with the applicant, who needs to provide their name and case number, and proceeds with an authorization for their employer to release pertinent income information. This step is foundational for establishing initial eligibility, with the understanding that further evidence of income will be required at subsequent evaluations. Employers play a significant role in this verification process, detailing the nature of the business, the employment specifics, and the compensation details of the employee. From the type of payment (be it cash, check, or otherwise) to the frequency and amount, every detail contributes to a comprehensive picture of the applicant's financial situation. Additionally, the form requests an outline of the employee's typical work schedule, offering a glimpse into their weekly commitments. This thorough approach underscores the importance of accuracy and honesty, as affirmed by the required signatures, thereby facilitating a smoother, more transparent eligibility assessment process for assistance programs aimed at enhancing the lives of children and families across Illinois.

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	cdvg verification income in waukegan il, il income verification, illinois act for children forms income verification, action for children verification form

How to Fill Out Income Verification

Income Verification at a glance

What it is: INCOME VERIFICATION: to be filled out by client and to be filled out by employer.

Who signs: Sign the Employee's Signature line and enter the Date. Before submitting, this form must be signed by your employer.

A filled-in Income Verification example: an employer verifies a client's income

Income Verification example filled out, example: an employer verifies a client's income — Dana Sample fills out the client part of the Income Verification form and Dana's employer, Pat Example, fills out the employer part. Pat pays Dana weekly by payroll check for 30 hours of work a week. The picture shows page 1, and all its values are invented. Dana earns 15 dollars per hour, so the gross amount per pay period is 450 dollars. Dana works Monday to Friday from 9 a.m. to 3 p.m. Dana receives no tips or commissions, so weekly tips or commissions stays empty. Dana does not work Saturday or Sunday, so Saturday and Sunday stay empty. Payroll check is ticked, so Other (please specify) stays empty.

How to fill out Income Verification, box by box

Client's Name, Case Number and Employee's Name

Enter the Client's Name and the Case Number.

Enter the Employee's Name. By signing, you authorize your employer to release the following information to Illinois Action for Children. This form is for initial eligibility purposes, and you will be asked to submit additional proof of your income with your next Redetermination. Action for Children may need to verify this information or contact the employer by phone.

Sign the Employee's Signature line and enter the Date.

Name of business, Business address and Start date of current employment

Enter the Name of business (if applicable), the Type of business or work performed, the Name of business owner or employer, the Business address, the Business phone and the Start date of current employment.

Hours worked and how the employee is paid

Enter the actual or average number of hours worked by the employee per week.

Check one for how the employee is paid: Cash, Personal check, Payroll check or Other (please specify).

Check one: the employee is paid Weekly, Biweekly, Semi-monthly or Monthly.

Enter the gross amount the employee receives per pay period. If the amount varies, please give the average amount.

Enter the employee's gross hourly wage per hour.

Enter the estimated amount of weekly tips or commissions the employee receives per week.

Typical work schedule

Please give the employee's typical work schedule: for Monday, Tuesday, Wednesday, Thursday, Friday, Saturday and Sunday, enter From and To. Circle either a.m. or p.m. in each applicable box.

Business Owner or Employer's Signature

Sign to verify that this information is true and correct to the best of your knowledge.

Business Owner or Employer's Signature and Date; Business Owner or Employer's SSN/FEIN and Phone.

Common questions about Income Verification

Where do I file it?

1340 S Damen Avenue 3rd Floor CHICAGO, IL 60608, phone: (312) 823-1100, fax: (312) 823-1200.

Sources

[1] Income Verification, Illinois Action for Children (printed CCAP_IV.doc rev. 8/10/2006; the served file; no issuer file found) (the Official source link on this page).