Get Action For Children Income Verification Form 2006-2025

CCAPIV. doc rev. 8/10/2006 INCOME VERIFICATION 1340 S Damen Avenue 3rd Floor CHICAGO IL 60608 phone 312 823-1100 fax 312 823-1200 Attention Client This form must be signed by your employer before submitting to our office. TO BE FILLED OUT BY CLIENT Client s Name Case Number Employee s Name I authorize my employer to release the following information to Illinois Action for Children. I understand this form is for initial eligibility purposes and that I will be asked to submit additional proof of my income with my next Redetermination. I understand that Action for Children may need to verify this information or contact the employer by phone. CCAPIV. doc rev* 8/10/2006 INCOME VERIFICATION 1340 S Damen Avenue 3rd Floor CHICAGO IL 60608 phone 312 823-1100 fax 312 823-1200 Attention Client This form must be signed by your employer before submitting to our office. TO BE FILLED OUT BY CLIENT Client s Name Case Number Employee s Name I authorize my employer to release the following information to Illinois Action for Children* I understand this form is for initial eligibility purposes and that I will be asked to submit additional proof of my income with my next Redetermination* I understand that Action for Children may need to verify this information or contact the employer by phone. Employee s Signature Date Name of business if applicable Type of business or work performed Business address Business phone Start date of current employment Actual or average number of hours worked by the employee per week The employee is paid by check one Cash Weekly Personal check Biweekly Payroll check Semi-monthly Other please specify Monthly The employee receives a gross amount of per pay period. If amount varies please give average amount. The employee s gross hourly wage per hour Monday From a*m* To p*m* Tuesday Wednesday Thursday per week Friday Saturday Sunday Please give the employee s typical work schedule. Circle either a*m* or p*m* in each applicable box. I verify that the above information is true and correct to the best of my knowledge. TO BE FILLED OUT BY CLIENT Client s Name Case Number Employee s Name I authorize my employer to release the following information to Illinois Action for Children* I understand this form is for initial eligibility purposes and that I will be asked to submit additional proof of my income with my next Redetermination* I understand that Action for Children may need to verify this information or contact the employer by phone. Employee s Signature Date Name of business if applicable Type of business or work performed Business address Business phone Start date of current employment Actual or average number of hours worked by the employee per week The employee is paid by check one Cash Weekly Personal check Biweekly Payroll check Semi-monthly Other please specify Monthly The employee receives a gross amount of per pay period. Employee s Signature Date Name of business if applicable Type of business or work performed Business address Business phone Start date of current employment Actual or average number of hours worked by the employee per week The employee is paid by check one Cash Weekly Personal check Biweekly Payroll check Semi-monthly Other please specify Monthly The employee receives a gross amount of per pay period. If amount varies please give average amount. The employee s gross hourly wage per hour Monday From a*m* To p*m* Tuesday Wednesday Thursday per week Friday Saturday Sunday Please give the employee s typical work schedule. .