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Get Child Care Council Verification Of Employment Contra Costa Form

VERIFICATION OF EMPLOYMENT STATEMENT OF RELEASE I authorize the release of employment verification information to the Contra Costa Child Care Council in order to determine eligibility for child care subsidies provided by the California Department of Education Child Development Division. I declare under penalty of perjury that the information provided below is true and correct to the best of my knowledge. EMPLOYEE NAME PRINT EMPLOYEE SSN OR ID EMPLOYEE JOB TITLE EMPLOYEE SIGNATURE PHONE DATE COMPANY PERSONNEL/PAYROLL DEPARTMENT USE ONLY In order to authorize child care services for the above named employee the following information is needed immediately and must be returned directly to the Contra Costa Child Care Council* Please note that your employee has given permission to release his/her employment or pending employment information* DATE EMPLOYMENT BEGAN OR WILL BEGIN / / OR DEPARTED OR WILL END / / EMPLOYEE SCHEDULE Day of Week Sunday Arrival Time Departure Time If flexible/vary please explain Monday Tuesday Wednesday Thursday Friday Saturday IF EMPLOYEE HAS A FLEXIBLE/VARIABLE SCHEDULE MINIMUM HOURS PER WEEK MAXIMUM HOURS PER WEEK DOES THE EMPLOYEE WORK OVERTIME NO YES PLEASE EXPLAIN EMPLOYEE EARNINGS SALARY PAYMENT SCHEDULE GROSS EARNINGS PER PAY PERIOD Frequency of employee s pay period check one MONTHLY TWICE A MONTH WEEKLY HOURLY EVERY OTHER WEEK DAILY IF YES HOW OFTEN I declare that the above mentioned information is true and correct to the best of my knowledge. Signature Company Representative Federal Identification Number/Social Security Title Date Print Name Phone No* Name of Company/Employer Employers hours of operation Company Address City Ext. Zip Code CHILD CARE COUNCIL USE ONLY Document verified by on the date of with company/employer representative Title. EMPLOYEE NAME PRINT EMPLOYEE SSN OR ID EMPLOYEE JOB TITLE EMPLOYEE SIGNATURE PHONE DATE COMPANY PERSONNEL/PAYROLL DEPARTMENT USE ONLY In order to authorize child care services for the above named employee the following information is needed immediately and must be returned directly to the Contra Costa Child Care Council* Please note that your employee has given permission to release his/her employment or pending employment information* DATE EMPLOYMENT BEGAN OR WILL BEGIN / / OR DEPARTED OR WILL END / / EMPLOYEE SCHEDULE Day of Week Sunday Arrival Time Departure Time If flexible/vary please explain Monday Tuesday Wednesday Thursday Friday Saturday IF EMPLOYEE HAS A FLEXIBLE/VARIABLE SCHEDULE MINIMUM HOURS PER WEEK MAXIMUM HOURS PER WEEK DOES THE EMPLOYEE WORK OVERTIME NO YES PLEASE EXPLAIN EMPLOYEE EARNINGS SALARY PAYMENT SCHEDULE GROSS EARNINGS PER PAY PERIOD Frequency of employee s pay period check one MONTHLY TWICE A MONTH WEEKLY HOURLY EVERY OTHER WEEK DAILY IF YES HOW OFTEN I declare that the above mentioned information is true and correct to the best of my knowledge. Signature Company Representative Federal Identification Number/Social Security Title Date Print Name Phone No* Name of Company/Employer Employers hours of operation Company Address City Ext.

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