Washington Form Af 595 PDF Details

The Washington AF 595 form is a crucial document handled by the Washington County Department of Job and Family Services, located at 1115 Gilman Avenue in Marietta, Ohio. This form serves as a formal request by the Department for businesses to provide detailed information regarding an employee's employment status, including start and end dates, reasons for termination, positions held, and compensation details. It also requires reporting on gross earnings over a specified period. This document is vital for assessing individuals' eligibility for public assistance benefits such as Aid to Dependent Children (ADC), Medicaid, Food Stamps, or other specified programs. The form emphasizes the responsibility of the individual to report accurately on matters affecting their eligibility for assistance. A clear warning is issued about the potential for civil action or criminal prosecution if inaccuracies that could affect eligibility are discovered through the information provided. Employers are requested to answer specific highlighted or underlined questions, underscoring the form's role in ensuring thorough and accurate communication between businesses and the Department. Aimed at enabling efficient determination of public assistance eligibility, the AF 595 form is a critical tool for both the Department and the individuals it serves, highlighting the collaborative effort between government agencies and employers in supporting residents in need.

QuestionAnswer
Form NameWashington Form Af 595
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesAF 595 washington county ohio job and family services form

Form Preview Example

Washington County Department of Job and Family Services

1115 Gilman Avenue

Marietta, Ohio 45750

(740) 373-5513

DATE: __________________________

RE: ______________________________

_________________________________

______________________________

(Name of Business)

(Social Security Number)

_________________________________

______________________________

(Address)

(Case Manager)

_________________________________

______________________________

(City, State, Zip)

(Case Number Unit)

I am aware of my responsibilities to report completely and fully all facts which bear upon my eligibility for public 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.

By my signature below, I hereby authorize the following information to be released to determine eligibility for Public Assistance benefits.

(Signature)

(Date)

Employer: Please answer all highlighted or underlined questions. Thank You.

1.

Date employment began: ___________________________

Date 1st pay due or received: __________________

2.

Date employment ended: ___________________________

Date last pay due or received: _________________

3.

Reason for termination: ____________________________

 

4.

Position: ___________________________

How often is employee paid: __________________

5.Average number of hours scheduled per week: _____________

(Please give best estimate if new position)

6. Hourly Rate: ___________

 

If salary, monthly amount: _________________________________

7. Please report below gross earnings paid on each pay date from ___________ to ___________

____________

________

____________

________

___________

___________

(Date paid)

(Amount)

(Date paid)

(Amount)

(Date paid)

(Amount)

____________

________

____________

________

___________

___________

(Date paid)

(Amount)

(Date paid)

(Amount)

(Date paid)

(Amount)

____________

________

____________

________

___________

___________

(Date paid)

(Amount)

(Date paid)

(Amount)

(Date paid)

(Amount)

______________________________________________________________________________________

(SIGNATURE OF PERSON SUPPLYING INFORMATION)

(PHONE)

(DATE)

Please provide all information requested. This information will be used to:

[] Determine eligibility for: [] ADC [] Medicaid [] Food Stamps [] Other Programs, specify: __________

[] Other use, specify: ___________________________________

[ ]original

[ ] copy

AF-595

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Washington Form Af 595 completion process described (step 1)

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The best ways to fill in Washington Form Af 595 portion 2

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