CCAP_IV.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: |
TO BE FILLED OUT BY EMPLOYER:
Name of business (if applicable):
Type of business or work performed:
Name of business owner or employer:
Business address:
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Business phone: ( |
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Start date of current employment: |
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Actual—or average—number of hours worked by the employee per week: |
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The employee is paid by (check one): Cash Personal check Payroll check Other (please specify): |
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The employee is paid (check one): |
Weekly Biweekly Semi-monthly |
Monthly |
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The employee receives a gross amount of $ |
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per pay period. (If amount varies, please give average amount.) |
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The employee’s gross hourly wage: $ |
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per hour |
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The employee receives weekly tips or commissions in this estimated amount: $ |
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per week |
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Monday |
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Tuesday |
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Wednesday |
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Thursday |
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Friday |
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Saturday |
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Sunday |
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From: |
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a.m. |
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a.m. |
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a.m. |
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a.m. |
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a.m. |
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a.m. |
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a.m. |
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p.m. |
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p.m. |
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p.m. |
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p.m. |
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p.m. |
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p.m. |
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p.m. |
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To: |
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a.m. |
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a.m. |
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a.m. |
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a.m. |
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a.m. |
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a.m. |
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a.m. |
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p.m. |
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p.m. |
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p.m. |
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p.m. |
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p.m. |
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p.m. |
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p.m. |
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Please give the employee’s typical work schedule. (Circle either “a.m.” or “p.m.” in each applicable box.) |
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I verify that the above information is true and correct to the best of my knowledge. |
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Business Owner or Employer’s Signature: |
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Date: |
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Business Owner or Employer’s SSN/FEIN: |
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Phone: |
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FOR INTERNAL USE ONLY |
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T- |
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