Ensuring access to childcare services is a critical aspect of supporting working families, particularly in Illinois where the collaboration between employees, employers, and the Department of Human Services plays a pivotal role. The Illinois Wage Verification form operates at the heart of this partnership, facilitating a transparent exchange of employment-related information crucial for childcare support. Designed to provide the Illinois Department of Human Services with accurate and verified data regarding an employee's wage, this form serves as a safeguard against misinformation and fraud, emphasizing the importance of integrity in securing childcare payments. It mandates employers to furnish detailed information about the employee's salary, job title, work schedule, and the nature of their payments, whether cash or otherwise. This process not only aids in the precise assessment of childcare benefits but also outlines employer responsibilities in ensuring veracity. The potential repercussions for providing misleading information are clearly outlined, signaling the seriousness with which the state treats childcare support. Unauthorized release of information and the verification methods, which may include phone calls, highlight the state's proactive stance in maintaining the integrity of childcare assistance programs. In essence, the form is a testament to Illinois' commitment to fostering a supportive environment for working parents, underscoring the collective responsibility in nurturing the future of the state's children.
| Question | Answer |
|---|---|
| Form Name | Illinois Wage Verification Form |
| Form Length | 1 pages |
| Fillable? | Yes |
| Fillable fields | 1 |
| Avg. time to fill out | 27 sec |
| Other names | wage pm, il444 3514 n 1 11, dhs wage verification form, wage verification form |
State of Illinois
`k~~~°' WAGE VERIFICATION
hereby authorize my employer to release the following information to the Illinois Department of Human Services. understand that this information may be verified by phone. Any fraudulent, false or misleading information given may result in loss of childcare payments and my child care case may be cancelled or denied.
Client Signature |
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Client Case Number |
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Date |
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JOB INFORMATION: TO BE COMPLETED BY YOUR EMPLOYER ONLY. |
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Employee Name: |
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Start Date: |
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Rate of Hourly Pay: |
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Commission: |
Tips: |
(Monthly Average) |
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Pay Period: |
Weekly: |
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Twice Per Month: |
Monthly: |
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Is the employee paid cash? |
❑ Yes |
❑ No |
Employee Job Title: |
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If on leave: |
Return Date: |
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Type of Leave: |
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WORK SCHEDULE: If your schedule varies, provide an example of your schedule.
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FROM |
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TO |
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Do these hours vary? |
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If yes, please explain: |
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Employer/Company Name: |
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Employer Address: |
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City: |
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Employer Phone Number: |
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Employer Name Printed |
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Title |
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Employer Signature |
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Date |
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PLEASE RETURN FORM TO: |
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Illinois Action For Children |
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THIS FORM MUST BE COMPLETED BY YOUR |
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1340 South Darren Avenue, 3rd Floor |
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EMPLOYER AND RETURNED TO THE ADDRESS |
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Chicago, IL 60608 |
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AT THE RIGHT WITHIN 10 BUSINESS DAYS. |
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