The Acd 1069 form is a federal tax form that, when filed correctly, provides individuals with the opportunity to reduce their taxable income. This form can be used by taxpayers who have unreimbursed business expenses and qualifying work-related education expenses.

What is CFWB 015 form?

CFWB-015 Referral to Employer for Employee Income Information.

Get 1069 Form 2002-2024

Nyc ACS ACD 1069 REV 6/02 NYC Administration for Children s Services REFERRAL TO EMPLOYER FOR EMPLOYEE INCOME INFORMATION Employee s Name Program Number Street Address RA Address City State Zip Code Social Security No. Att. To be completed by employer s personnel or payroll department The above named individual is requesting/receiving publicly funded day care services. To make a financial eligibility determination it is necessary to verify income for the last three 3 months. Please list overtime if any in the appropriate column* Do NOT include time and leave penalties in the REGULAR GROSS column* Period of Employment Start Date / / To / / Type of Work No* of Work Days Per Week Hours Daily From To Circle Regular Work Days MON TUE PERIOD ENDING HOURS WORKED REGULAR GROSS PAY Regular Gross WED OVERTIME / TIPS THU FRI Per SAT SUN OTHER EARNINGS AMOUNT TYPE Name of Employer Employer s Address Employer s Federal ID Number Tel* No Signature Title Note It may be necessary to verify the income information by telephone. To be completed by employer s personnel or payroll department The above named individual is requesting/receiving publicly funded day care services. To make a financial eligibility determination it is necessary to verify income for the last three 3 months. To make a financial eligibility determination it is necessary to verify income for the last three 3 months. Please list overtime if any in the appropriate column* Do NOT include time and leave penalties in the REGULAR GROSS column* Period of Employment Start Date / / To / / Type of Work No* of Work Days Per Week Hours Daily From To Circle Regular Work Days MON TUE PERIOD ENDING HOURS WORKED REGULAR GROSS PAY Regular Gross WED OVERTIME / TIPS THU FRI Per SAT SUN OTHER EARNINGS AMOUNT TYPE Name of Employer Employer s Address Employer s Federal ID Number Tel* No Signature Title Note It may be necessary to verify the income information by telephone. To be completed by employer s personnel or payroll department The above named individual is requesting/receiving publicly funded day care services. To make a financial eligibility determination it is necessary to verify income for the last three 3 months. Please list overtime if any in the appropriate column* Do NOT include time and leave penalties in the REGULAR GROSS column* Period of Employment Start Date / / To / / Type of Work No* of Work Days Per Week Hours Daily From To Circle Regular Work Days MON TUE PERIOD ENDING HOURS WORKED REGULAR GROSS PAY Regular Gross WED OVERTIME / TIPS THU FRI Per SAT SUN OTHER EARNINGS AMOUNT TYPE Name of Employer Employer s Address Employer s Federal ID Number Tel* No Signature Title Note It may be necessary to verify the income information by telephone. .

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