Get NH DHHS DFA 756 2015-2024

NH Department of Health and Human Services DHHS Division of Family Assistance DFA Employment Verification DFA Form 756 07/07 Rev 8/15 Completed by Employer Only FROM Eligibility Worker Name Telephone Centralized Scanning Unit CSU P. O. Box 181 Concord NH 03301 Today s Date Please complete and return by FOR CURRENT EMPLOYMENT Name of Employee SSN Date of Hire - Job Title Av* Hrs per Week Current Rate of Pay per st EIN If this is new employment the date of the 1 paycheck Frequency of pay circle one Weekly Bi-weekly Monthly Semi-monthly Please indicate if the employee has any of the following deductions Credit Union Account s Share/Profit Sharing Retirement Fund/IRA Mandatory Wage Assignment i*e* Child Support Assignment Medical Insurance Savings Bond s Self Family Do you anticipate any changes in rate of pay or hours Yes use back of form to explain No FOR TERMINATED EMPLOYMENT Date of Termination or Leave of Absence Circle One Permanent Temporary Reason for Termination Actual Date Final Paycheck Received Gross Amount of Final Paycheck Did the employee receive money from any other sources Y N If yes please indicate source type amount i*e* severance pay worker s comp etc* End Date COBRA COMPLETE THIS SECTION FOR BOTH CURRENT AND TERMINATED EMPLOYMENT Please list the employee s gross wages for the last 4 weeks and indicate all bonuses tips or commissions that are not already included in the gross wages. If the employee receives an Earned Income Tax Credit EITC indicate the amount of the credit. If not already included in Gross Wages Actual Date Paid Gross Wages EITC of Hours Additional Information Requested by the Department Tips Bonus Commission Signature Title of Person Completing this Form Date Company Telephone Number Company Address Fax Number Thank you for your cooperation* DFA SR 07-05 3YC. O. Box 181 Concord NH 03301 Today s Date Please complete and return by FOR CURRENT EMPLOYMENT Name of Employee SSN Date of Hire - Job Title Av* Hrs per Week Current Rate of Pay per st EIN If this is new employment the date of the 1 paycheck Frequency of pay circle one Weekly Bi-weekly Monthly Semi-monthly Please indicate if the employee has any of the following deductions Credit Union Account s Share/Profit Sharing Retirement Fund/IRA Mandatory Wage Assignment i*e* Child Support Assignment Medical Insurance Savings Bond s Self Family Do you anticipate any changes in rate of pay or hours Yes use back of form to explain No FOR TERMINATED EMPLOYMENT Date of Termination or Leave of Absence Circle One Permanent Temporary Reason for Termination Actual Date Final Paycheck Received Gross Amount of Final Paycheck Did the employee receive money from any other sources Y N If yes please indicate source type amount i*e* severance pay worker s comp etc* End Date COBRA COMPLETE THIS SECTION FOR BOTH CURRENT AND TERMINATED EMPLOYMENT Please list the employee s gross wages for the last 4 weeks and indicate all bonuses tips or commissions that are not already included in the gross wages. If the employee receives an Earned Income Tax Credit EITC indicate the amount of the credit. If not already included in Gross Wages Actual Date Paid Gross Wages EITC of Hours Additional Information Requested by the Department Tips Bonus Commission Signature Title of Person Completing this Form Date Company Telephone Number Company Address Fax Number Thank you for your cooperation* DFA SR 07-05 3YC. .