Office Use Only: CM: __________________ Family ID: _____________ Providing Services to Families, Children and Seniors Employment Verification Form Section 1: Employee information and Verification (To be completed and signed by EMPLOYEE. Para ser completado y firmado por el empleado.) Imprimir nombre: Apellido: Primer nombre: Dirección: Ciudad: Estado: Código postal: Teléfono: Empleador (Business Nombre): Días & Horas de operación : Dirección de Negocios: Ciudad: Teléfono de negocio Fax del trabajo (Si procede): Estado: Código Postal: I declare that I am the person stated above and that I authorize my employer to release all information requested on this form to the 4C Council. Declaro que soy la persona arriba indicada y que autorizo a mi empleador para liberar toda la información solicitada en este formulario para el 4C Council. Firma del empleado Fecha Section 2: Employer information and Verification (To be completed by EMPLOYER) This business participates in The Work Number. The Employer code is: __________ Employee Information Date of Hire: Date of Rehire or return from Leave of Absence if applicable: If employee works FIXED schedule, complete section A A. Monday Tuesday Total work hours per week ____________ Wednesday Thursday Friday Saturday Sunday Start End If employee works VARIABLE schedule, complete section B B. What is the number of hours per week this employee may work: Min: __________ Max: ___________ What is the number of days per week this employee may work: Min: __________ Max: ___________ Earliest Start Time :________________________ Latest end time: ____________________________ Check days employee MAY work: Monday Tuesday Wednesday Thursday Hourly Rate: _________ OR Gross Monthly Salary: ____________ Pay Frequency: Weekly Is there possible overtime? Employee Receives: Bi-Weekly Yes Commission No Friday Saturday Is Employee paid cash: Semi-Monthly Sunday Yes No Monthly If yes, is it reoccuring? _____________ Bonuses Tips Average Monthly Amount: __________ (If more space is needed to provide information regarding parent’s employment, see other side of form to add comments) I declare the above statements to be true and correct to the best of my knowledge. I understand the above information pertains to the employee’s eligibility for child care benefits and is subject to review by representatives of the State of California. Authorized Employer Representative (Print Name) Signature of Authorized Representative Title Date 150 River Oaks Parkway, Suite F-1 | San Jose, CA 95134 | P. 408.487.0747 | F. 408.321.7454| www.4C.org Revised April 2016 Providing Services to Families, Children and Seniors Comments: ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ For Office Use Only: First Attempt Name of Authorized Employer Representative: Position: 4C Council Employee: Phone Number: Date/Time: Second Attempt Name of Authorized Employer Representative: Position: 4C Council Employee: Phone Number: Date/Time: Third Attempt Name of Authorized Employer Representative: Position: 4C Council Employee: Phone Number: Date/Time: 4C Employee to complete the following: I, _________________________________________________, hereby attest that the employer: Refused to provide information regarding the parent’s employment Is non-responsive to requests for information Provided information over the phone to the authorized 4C representative As an authorized representative of the 4C Council, I attest to the reasonableness of the Participant’s request for services based on the description of employment and accepted community practice. 4C Council Employee Signature: Date/Time: 150 River Oaks Parkway, Suite F-1 | San Jose, CA 95134 | P. 408.487.0747 | F. 408.321.7454| www.4C.org Revised April 2016