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Download this Employer Verification of Earnings that is intended for agency/employer use only and is used for the purpose of verifying information for agencies that require direct receipt of earnings information from a current or past employer. The agency who would like to make an inquiry, would simply acquire written permission from the employee, include this form and mail the documents to the current employer to verify the earnings information needed. The agency would then answer the inquiry and mail it back to the agency.

How To Write

Step 1 – Must be completed by the employer only –

Employer Information –

  • The person(s) making the inquiry would begin by completing the employee information for which the inquiry is being made:
  • Please return this form by: (mm/dd/yyyy)
  • “To”- (the person(s) making the inquiry
  • Employer Information (Name of employer, complete address
  • Fein- (federal Tax ID)
  • Fax Number

Employee Information –

  • Request the following information:
  • Employee Name
  • Employee Address
  • Employee City, State, Zip

Step 2 – Section 1 – Employee Status –

  • This section is to be completed by employees current or recent employer:
  • Is the employee listed above currently employed by your company? ( check yes or no, if yes, complete section 2)
  • If the answer is “no,” indicate employment end date mm/dd/yyyy
  • Reason employment ended (check the appropriate box)
  • Date of final paycheck – mm/dd/yyyy
  • Gross pay for final month (provide dollar amount)

Step 3 – Section  2 – Employment Information –

  • Employer must provide the following:
  • Start date of employment mm/dd/yyyy
  • Employee type (check the box(s) that apply)
  • Date first paycheck was received – mm/dd/yyyy
  • Complete the following columns:
  • Type of pay
  • Best Estimate of Hours Worked Per Week
  • Rate of Pay Per Hour
  • Regular Scheduled Work Hours

Gross Per Pay Period-

  • Salary if not paid hourly
  • Bonus and /or Commissions
  • Cash and/or tips
  • Frequency of Pay (check the box that applies)
  • Signature of Employer or Designee
  • Date Signed
  • Print Name of Employer or Designee
  • Telephone Number
  •  Title
  • Fax Number
  • If employer has comments, place them in the block provided