EMPLOYMENT VERIFICATION
EMPLOYMENT VERIFICATION
DATE
EMPLOYER: PROPERTY
ADDRESS: ADDRESS:
CITY, STATE, ZIP CITY, STATE, ZIP
CONTACT CONTACT:
TEL: FAX: TEL: FAX

The individual below named directly below is an applicant/tenant of a housing program that requires verification of income. The information provided will remain confidential to satisfaction of the stated purpose only. Please complete the section below and return it to our phone number listed above or if you have received via US Mail, return it in the enclosed self-addressed envelope. Thank you!

NAME OF EMPLOYEE:_________________________________DDITIONAL INFO

RELEASE STATEMENT
I hereby authorize the above named management agent to make inquiries regarding release of employment for the purpose of determining my eligibility for occupancy.

SIGNATURE DATE
THE FOLLOWING TO BE COMPLETED BY EMPLOYER (preferably from the payroll dept.)
(Please provide information for all fields)
Employee’s Position: __________________________________ Hire Date: _____________ End Date: ____________
Average hours worked per week:____________________
Hourly rate of pay:________________________________ Over time Rate: _____________________
If salaried, what is gross weekly pay?_________________ Average over time per week__________hrs.
Average months worked per year:____________________

Has there been an increase or decrease in pay/wage within the past 12 months? Yes No
If yes, indicate effective amount date(s) and amount of increase/decrease:__________________________________

Is an increase in pay/wage expected within the next 12 months? Yes No
If yes, indicate effective amount date and amount of increase:_______________________________________________

Does employee receive other forms of compensation? Yes No Overtime: what is the average Overtime hours worked per week?_________________________ Bonuses: what is estimated amount and frequency of bonus?_____________________________ Commission: explain commission plan and estimated earnings per month______________________________________________
___________________________________________________________________________________________________________
Shift differential pay/month:_______________________________________________________________________________ Seasonal employee, indicate the layoff period:___________________________________ Historical Earnings Information | Year to date earnings | Previous year’s earning | Base pay/salary | $ FROM: TO | $ | Overtime | $ FROM: TO | $ | Other (specify): | $ FROM: TO | $ |

* AUTHORIZED REPRESENTATIVE (PREFERABLY SOMEONE FROM THE PAYROLL DEPT)
I certify I am authorized to complete this form and the above information is true and correct to the best of my knowledge.
SIGNATURE/TITLE DATE

PRINTED NAME TELEPHONE FAX

EMPLOYMENT VERIFICATION
EMPLOYMENT VERIFICATION
WARNING: Section 1001 of the tile 18 U.S. code makes it criminal offense to make willful, false statements or misrepresentation of any material fact involving the use of or obtain federal funds.