Employment Verification

This individual is a member of a household applying for health care assistance. To determine the household's eligibility, it is necessary to verify all earnings. Since this individual is/was/will be your employee, your help is needed.

Please completely and accurately provide the information requested on this form. If a question does not apply, mark it N/A. After you complete the form, you may give it to your employee, mail it, or fax it to the number listed above.

Thank you for your assistance. If you have any questions, contact our office at the number above.

I give my permission to release the information requested on this form.