Mcdjfs 113 Form – Fill Out and Use This PDF

Employer's Name:

Employee's Name:

Address:

Social Security Number:

City:

State:

Zip:

AG Name:

MCDJFS Worker's Signature:

AG Number:

Phone:

UNID

Date:

DATE INFORMATION IS NEEDED:

EMPLOYER:

Please complete the information below as it appears in your files. Return to the worker listed above by the date entered in

the "DATE INFORMATION IS NEEDED" box above.

Employee's Full Name:

Position:

Currently employed?

~

No;

~

Yes

Address:

Is position permanent?

Federal Work Study?

No. of dependents claimed:

~

No;

~

Yes

~

No; ~

Yes

Date(s) employment

Date(s)

Date last check

Type of separation:

Eligible for rehire?

Reason for quit or discharge:

began:

terminated:

received:

Discharge

No

~

~

~

Laid off

~

Yes, When?

~

Illness/Injury

~

Quit

Social Security Number:

Rate of Pay: (hourly)

Paid: ~

weekly;

biweekly; ~

daily;

other:

~

~

What day of week paid? (circle)

S

M

T

W TH

F S

Date of Birth:

Union member? (If yes, list name/local.)

Does pay include overtime? ~

No; ~ Yes

~

No

If yes, how long will it continue?

~

Yes

Does employee receive tips?

Do you record tips?

Does employee receive EITC?

Was a W-2 filed the preceding year?

~

No;

~

Yes

~ No; ~ Yes

~

No;

~

Yes

~

No; ~

Yes

Is employee scheduled to work a set # of hours per week?

Are these

HOURS

S

M

T

W

TH

F

S

~

Yes

-

# of hours scheduled per week:

hours?

Begin:

Actual

~

No

-

Average # of hours worked per

week:

~

~

Proposed

End:

Type of current Medical Insurance coverage?

Medical Insurance:

Policy No.:

~

Went into effect: (Date)

;

Monthly cost to employee: $

~

Will become effective: (Date)

;

Monthly cost to employee: $

Deadline date for continuation of insurance under COBRA:

~

Expired/will expire: (Date)

Eligible for severance pay?

Date check issued:

Gross amount of check:

Any deductions?

~

No;

~

Yes

$

~

No;

~

Yes; $

Eligible for sick benefits?

Date of first sick

Gross amount of check:

Any deductions?

Date of last sick benefit check:

No;

Yes

benefit check:

$

No;

Yes; $

~

~

~

~

Eligible for Unemployment Compensation?

Worker's Compensation Claim Filed?

Date filed:

~

No;

~

Yes

~

No; ~

Yes; Claim #

Year-to-date earnings:

Total earnings for the last 2 most recent years of employment:

(Year)

$

(Year)

$

;

(Year)

$

Signature of Person

Title:

Employer I.D. #

Phone:

Date:

Supplying Information:

Please complete the information on the reverse for the period

thru

.