Job And Family Services Hamilton Ohio Form PDF Details

In the realm of public assistance and employment verification within Hamilton County, Ohio, the Job and Family Services Hamilton Ohio form serves as a critical document facilitating communication between employers and the Southwest Ohio County Departments of Job & Family Services. Located at 222 E. Central Parkway in Cincinnati, this agency requires the completion of this form to verify employment details crucial for determining eligibility for various assistance programs such as Cash Assistance, Food Assistance, Medical Assistance, among others. The form, detailed in its requirements, mandates the employer to furnish information regarding the employee's dates of employment, wages, potential benefits, and the reason for separation if applicable, underscoring the comprehensive nature of Ohio's approach to verifying eligibility and ensuring aid reaches those genuinely in need. It emphasizes the legal framework governing such inquiries, including the agreement of applicants to permit the investigation into their circumstances as mandated by Ohio Revised Code 5101.37, and the potential for criminal prosecution should misinformation be revealed. This document underscores the interconnectedness of public assistance programs, employers, and the legal obligations of individuals seeking aid, highlighting the thorough processes in place to maintain integrity and fairness in the distribution of public resources.

QuestionAnswer
Form NameJob And Family Services Hamilton Ohio Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesjob and family services hamilton ohio, job and family services employment verification form, hamilton county jfs forms, ohio employment verification form

Form Preview Example

Southwest Ohio

County Departments of

Job & Family Services

County Agency: Hamilton County Job & Family Services

Address: 222 E. Central Parkway, Cincinnati, OH 45202 Phone: (513) 946-1000 Fax: (513) 946-1076 Website: www.hcjfs.org

Employment Verification Request

JFS Worker:

Phone:

Date:

Return by:

 

 

 

 

Employer Name:

 

 

Employee Name:

 

 

 

 

Employer Address:

 

 

Social Security Number:

 

 

 

 

City:

State:

Zip:

Case Number:

 

 

 

 

By applying for CDJFS programs, the individual has agreed that the CDJFS may contact other persons or organizations to obtain the necessary proof of eligibility and level of assistance. In addition, Ohio Revised Code 5101.37 authorizes the CDJFS to make investigations that are necessary in the performance of their duties.

Authorization for Release of Information

I agree that the employer named below may release my employment information to Hamilton County Job & Family Services & the Cincinnati Metropolitan Housing Authority.

This information will be used to determine eligibility for:

Cash Assistance;

Food Assistance;

Medical Assistance;

Other, specify:

 

.

I am aware of my responsibilities to report completely and fully all facts which bear upon my eligibility for assistance. I realize if the requested information reveals I have improperly reported my situation, the information may be given to the prosecuting attorney for possible civil action or criminal prosecution.

Signature of Applicant/Recipient:Date:

Employer to Complete

Dates of Employment

 

Corporate Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If employment has ended, also complete this section.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Employment Site:

 

 

 

 

 

 

 

 

 

 

 

 

Last Day Worked:

Date Last Pay Received:

Type of Separation:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

First Day Worked:

 

 

 

 

 

 

 

 

 

 

 

 

 

Laid Off

Illness or Injury

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No Call or Show

Other (specify): ____________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Resignation

Eligible for Post-Employment Benefits (specify):

 

 

 

 

 

 

Date First Pay Received:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Discharged

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

List interruption or leave period during employment.

 

 

 

 

 

 

Strike Start Date:

 

 

 

 

 

Strike End Date:

 

Effective Lockout Date:

 

From Date:

 

 

 

 

 

To Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Rate/Hours/Pay Frequency

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Current Hourly Rate:

 

Day of Week Paid:

 

Pay Period Frequency:

 

 

 

 

 

 

Overtime is:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Weekly

 

Twice Monthly

 

 

 

 

 

 

 

Not expected to be worked in the future

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Biweekly

 

Other (Specify)

 

 

 

__

 

 

 

 

Worked routinely monthly

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Number of set hours to work per Week:

 

 

 

 

 

; OR

Number of hours will vary from __________ to __________ per Week

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Wages (Last 6 Pays)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date

 

 

 

 

 

 

 

Hourly

 

 

Gross Pay

 

 

 

 

 

 

 

Bonus or

 

 

 

 

 

 

 

 

Child Support

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Period Ending

 

 

 

 

 

Hours

 

 

 

 

 

WITHOUT Tips, Bonus

 

 

Tips

 

 

 

 

 

 

Garnishment

 

 

 

 

 

 

 

Received

 

 

 

 

 

 

Rate

 

 

 

 

 

 

 

Commission

 

 

 

 

 

Deduction

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

or Commission

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Health Insurance

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is the employee or their dependents enrolled in health insurance?

Begin Date:

 

End Date:

 

Policy Number:

 

Group Number:

 

No

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name/Address of Insurance Company:

 

 

 

 

 

 

 

 

 

 

 

 

List Covered Members:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Additional Information Needed For Time Period Below (See Reverse only if Time Period is Noted Below)

 

 

 

 

 

 

 

 

Time Period Requested – From Date:

 

 

 

 

 

 

 

 

 

 

 

 

To Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer Signature

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer Representative Signature:

 

 

 

 

 

 

 

 

 

 

Title:

 

 

 

 

 

Phone:

FAX:

 

 

 

 

Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SWOJFS 2775 (REV. 10-12)

Page 1 of 2

(SWOJFS 3)

Employee Name:

Employee Social Security Number:

If indicated on the front side, complete the following information for the time period indicated on page 1 of this form. If it is more convenient or you need more space, please substitute copies of the employee’s payroll records.

Date Pay Received

Gross Pay Without Tips, Bonus or Commission

Tips

Bonus or

Commission

Garnishment

Child Support

Deduction

Other Information Requested

Requested Information:

Employer Response to Requested Information:

Employer Signature

Employer Representative Signature:

Title:

Date:

 

 

 

Phone:

FAX:

SWOJFS 2775 (REV. 10-12)

Page 2 of 2

(SWOJFS 3)

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Completing segment 1 of hcjfs employment verification form

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Child Support, Date Pay Received, and Employee Name of hcjfs employment verification form

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Learn how to fill out hcjfs employment verification form portion 3

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