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Get FL Kidcare Employment Statement

Please assist us by answering the following questions for the employee listed above and returning this form to Florida KidCare PO Box 591 Tallahassee Florida 32302-0591. FLORIDA KIDCARE EMPLOYMENT STATEMENT General Directions Copy this form and have it completed by each employer that provides income to a family member on the KidCare application. If you provide recent pay stubs you do not need this form completed. Complete Section A and submit to employer for completion. Completed form must be returned to Florida KidCare P O Box 591 Tallahassee Florida 32302-0591. Section A To Be Completed by Employee Family Account Number I authorize the release of employment information for the purpose of determining KidCare eligibility. Employee Signature Date Employee Name Employee SSN please print Directions This information is needed to help determine eligibility for KidCare Health Insurance. 1 Number of Hours Worked Per Week Number of Days Worked Per Week 2 How often is the employee paid Daily Weekly Bi-Weekly Monthly Twice Monthly Other explain 3 Rate of gross pay per Other Hour/Day/Week/etc* 4 If hours or rate of pay has varied in the above period please state why include tip information here 5 Employer Statement What I have written on this form is true to the best of my knowledge. I know that if I give false information on purpose I may be subject to prosecution for fraud. Signature of Employer Employer s Title Name of Employer please print Name of Business Date Completed Business Address City State Zip T24m. Section A To Be Completed by Employee Family Account Number I authorize the release of employment information for the purpose of determining KidCare eligibility. Employee Signature Date Employee Name Employee SSN please print Directions This information is needed to help determine eligibility for KidCare Health Insurance. 1 Number of Hours Worked Per Week Number of Days Worked Per Week 2 How often is the employee paid Daily Weekly Bi-Weekly Monthly Twice Monthly Other explain 3 Rate of gross pay per Other Hour/Day/Week/etc* 4 If hours or rate of pay has varied in the above period please state why include tip information here 5 Employer Statement What I have written on this form is true to the best of my knowledge. I know that if I give false information on purpose I may be subject to prosecution for fraud. Signature of Employer Employer s Title Name of Employer please print Name of Business Date Completed Business Address City State Zip T24m. .

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