Scribd Logo
Upload

Welcome to Scribd!

  • 14 views

    Work Verification

    Uploaded by

    chelseareimers

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Work Verification

    Uploaded by

    chelseareimers
    14 views1 page

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    14 views1 page

    Work Verification

    Uploaded by

    chelseareimers

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    Rev.

    4/13/2016 | HW0411
    Only your employer or payroll clerk may complete and sign this form.
    How to use this form 1. Send the completed form to the Department by mail, fax, or email.
    2. Contact us if you or your employer have questions about the form.

    Contact the Department Mail: PO Box 83720 Boise, ID 83720-0026


    Phone: 1-877-456-1233
    Fax: 1-866-434-8278
    E-mail: [email protected]
    Employee Information (Please print)
    Name of Employee: Social Security Number:
    Wage Information
    Date Employee Started:
    Hourly Pay $ Per hour Average number of hours per week:
    Monthly Salary $ Per month Number of days worked per week:
    Other $ Per:
    Other Income
    Employee receives (mark all that apply):
    Type Tip Housing/Utilities Commissions Bonuses Overtime
    Amount $ $ $ $ $
    How often?
    Is overtime anticipated?
    No Yes. If yes, estimate the number of hours per week: per month:
    If employee just started working, date first check will be issued:
    Number of hours this check covers:
    Pay Date Information
    Employee is paid (mark one of the following):
    Weekly Bi-weekly (every two weeks) What day of the week?
    Monthly Semi-monthly (twice a month) What date (e.g. 1st & 5th)?
    Date and day of the week pay period ends. Day: Date:
    Number of days between the pay period ending date and the date paid:
    Expected Changes
    Do you expect the number of hours to increase or decrease? No Yes. If yes, what date?
    New number of hours: Per:
    Do you expect the rate of pay to increase or decrease? No Yes.
    If yes, what date? New rate of pay: $ Per:
    Employer Information (Please print)
    If your employee completed any part of this form, DO NOT SIGN THE FORM. Instead, have your employee
    provide a blank replacement form to complete.
    Employer Name (First and Last): Phone Number:

    Business Name: Email:

    Address:
    Signature: Under penalty of perjury, I swear or affirm the information I have reported is true and complete.
    Employer/Payroll signature: Date:

    You might also like