Loss Of Income Details

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.

QuestionAnswer
Form NameVerification Of Employment Loss Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesemployment loss income, verification employment loss income form, fl loss income form, access florida employment verification form

Form Preview Example

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

Bi-Weekly

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:______________________________________________________________________________

CF-ES 2620, PDF 09/2002

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 CF-ES 2620

 

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