Employment verification is an important process for both employees and employers. When an employee leaves a job, they may need to provide documentation to their new employer proving that they have indeed left their previous position. The Verification of Employment Loss Form can help make this process easier for everyone involved. This form can be used by former employees to confirm employment termination and by employers to document the date of termination. By using the Verification of Employment Loss Form, both employees and employers can avoid any potential confusion or issues down the road.
This figure provides details about verification of employment loss form. There, you will discover the specifics of the document you want to fill in, such as the likely time required to fill it out along with other particulars.
| Question | Answer |
|---|---|
| Form Name | Verification Of Employment Loss Form |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | employment loss income, verification employment loss income form, fl loss income form, access florida employment verification form |
VERIFICATION OF EMPLOYMENT/LOSS OF INCOME
Date: ________________________
___________________________________________
___________________________________________
___________________________________________
In order to determine the eligibility of ___________________________________________ for public assistance,
please assist us by answering the questions below and returning this form to us by __________________________ .
______________________________________________
Case Name
______________________________________________
Case Number/Cat/Seq./SSN
Office Address / Phone Number:
Please complete each section which has been marked on PAGE 1 and PAGE 2 of this form.
Section I – GENERAL INFORMATION
1.Name of Employee:________________________________________ Social Security Number:____________________
Address:_________________________________________________________________________________________
2.Job Title:_________________________________________ Type of Work Performed:___________________________
3. |
Number of Hours Worked Per Week:________________ |
Number of Days Worked Per Week:_______________ |
||||||
4. |
A. How often is/was the employee paid? |
Day |
|
Week |
Monthly |
|||
|
B. Rate of pay: $___________ per ___________ . |
Other ____________________________________________ |
||||||
|
|
H r . / D a y / W k . / e t c . |
|
|
(Explain) |
|
||
5. |
Date current employment began:___________________ |
Date previously employed:____________________________ |
||||||
6. |
Does/did employee receive tips? |
Yes |
No (If yes, please show tips in Section III.) |
|
||||
7. |
Is/was employment seasonal? |
Yes |
No If yes, season begins:_______________ ends:_______________ |
|||||
8. |
Is/was the employee covered by health insurance? |
Yes |
No |
|
|
|||
|
If yes, name of insurance company:____________________________________________________________________ |
|||||||
9. |
Number of dependents covered:________________ |
|
|
|
|
|
||
10. |
Does/did the employee participate in any type of payroll savings plan or profit sharing? |
Yes |
No |
|||||
|
If yes, what is the balance? $____________________ |
|
|
|
|
|
||
11. |
Does the person perform their job duties: |
in their home |
|
in your home |
N/A |
|
||
Section II – LOSS OF INCOME
1.Date employment ended:___________________________________
2.Reason for termination:______________________________________________________________________________
3. |
Is the loss of income |
Permanent or |
Temporary? If temporary, when do you expect the employee |
|||
|
to return to work? __________________________________________________________________________________ |
|||||
4. |
Date employee received final check:___________________________ |
Gross amount: $____________________ |
||||
|
(Please list last 8 weeks in Section III.) |
|
|
|
|
|
5. |
Will employee receive any vacation pay, retirement refund, or other? |
Yes |
No |
|||
|
If yes, what type? _____________________ |
Date received:___________________ Amount: $________________ |
||||
6. |
Is employee eligible for any type of benefits from your company, such as extended insurance coverage, workers’ |
|||||
|
compensation, or other? |
Yes |
No |
If yes: |
|
|
A.Name of insurance company:_______________________________________________________________________
B.Reason for benefits:______________________________________________________________________________
Page 1 of 2 |
Section III – RECORD OF PAY RECEIVED
List the gross amounts and dates of checks or cash, which were paid for the last eight weeks in the space below.
Pay Period Ending Date Pay Received GROSS Earnings
No. of
Regular
Hours
Worked
Rate of Pay
No. of
Overtime
Hours
Rate of Pay for
Overtime
Tips $$
Earned Income
Credit (EIC)
If hours or rate of pay has varied in the above period, please state why.
Section IV – EMPLOYER INFORMATION
What I have written on this form is true to the best of my knowledge. I know that if I give false information on purpose, I may be subject to prosecution for fraud.
_______________________________________________________ |
____________________________________ |
|
|
Signature of Employer |
Employer’s Title |
_______________________________________________________ |
____________________________________ |
|
|
Name of Business |
Telephone Number |
_______________________________________________________ |
____________________________________ |
|
|
Address |
Date Completed |
_______________________________________________________ |
|
|
|
|
|
Back to |
|
|
Page 2 of 2