Job And Family Services Hamilton Ohio Form PDF Details

Are you looking to apply for financial aid, food assistance, and/or child care in the Hamilton area? The Job and Family Services of Hamilton Ohio makes it easy to get started with their online application forms. Whether you’re just getting started or trying to renew benefits, these simplified forms provide an efficient way to take your first step towards securing family services. In this post, we'll take a closer look at what kind of help the Job and Family Services stands ready to offer local families in town – from eligibility requirements all the way through filing out the required paperwork.

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

2. Once your current task is complete, take the next step – fill out all of these fields - Employee Name, Employee Social Security Number, If indicated on the front side, Date Pay Received, Gross Pay Without Tips Bonus or, Tips, Bonus or, Commission, Garnishment, Child Support, and Deduction with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

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

When it comes to Child Support and Date Pay Received, be sure that you review things in this current part. Both these are thought to be the key fields in this file.

3. Your next part is usually easy - fill out every one of the fields in Other Information Requested, Employer Response to Requested, Employer Signature Employer, Title, Date, FAX, SWOJFS REV, Page of, and SWOJFS in order to finish this process.

Learn how to fill out hcjfs employment verification form portion 3

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