State of Illinois
Department of Human Services - Bureau of Child Care and Development
WAGE VERIFICATION
I hereby authorize my employer to release the following information to the Illinois Department of Human Services. I understand that this information may be verified by phone. Any fraudulent, false or misleading information given may result in loss of childcare payments and my child care case may be cancelled or denied.
Client Signature
Client Case NumberDate
JOB INFORMATION: TO BE COMPLETED BY YOUR EMPLOYER ONLY.
Employee Name: |
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Start Date: |
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Rate of Hourly Pay: |
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Commission: |
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Tips: |
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(Monthly Average) |
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Pay Period: |
Weekly: |
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Bi-Weekly: |
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Twice Per Month: |
Monthly: |
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Is the employee paid cash? |
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Yes |
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No |
Employee Job Title: |
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If on leave: |
Return Date: |
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Type of Leave: |
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WORK SCHEDULE: If your schedule varies, provide an example of your schedule. |
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MON |
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TUES |
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WED |
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THURS |
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FRI |
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SAT |
SUN |
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FROM |
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AM |
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PM |
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PM |
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PM |
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PM |
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PM |
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PM |
PM |
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TO |
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AM |
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PM |
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PM |
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PM |
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PM |
PM |
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Do these hours vary? |
If yes, please explain: |
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Employer / Company Name: |
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Employer Address: |
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City: |
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Employer Phone Number: |
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Employer Name Printed |
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Title |
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Employer Signature |
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Date |
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PLEASE RETURN FORM TO: |
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THIS FORM MUST BE COMPLETED BY YOUR
EMPLOYER AND RETURNED TO THE ADDRESS
AT THE RIGHT WITHIN 10 BUSINESS DAYS.
IL444-3514 (N-1-11) |
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