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Get WA DSHS 14-252(X) 2015-2024

DSHS MAILING ADDRESS Employment Verification DSHS PO BOX 11699 TACOMA WA 98411-9905 DSHS PHONE NUMBER DSHS FAX NUMBER 888-338-7410 CASE / CLIENT ID NUMBER DATE Please use blue or black ink and print or type. Section 1 To be filled out by the client/employee. I authorize my employer to release information to the Department of Social and Health Services. EMPLOYEE S SIGNATURE SOCIAL SECURITY NUMBER OPTIONAL EMPLOYEE S NAME EMPLOYEE S JOB TITLE EMPLOYER S ADDRESS DATE EMPLOYEE STARTED WORK Is this a new job No AVERAGE HOURS PER WEEK Pay frequency RATE OF PAY OR SALARY HOURLY DAILY OR PIECE RATE Daily Is this job Work Study Yes DATE FIRST CHECK WAS RECEIVED Weekly Has job ended If yes when Every two weeks why Two times a month IF YES PROVIDE VERIFICATION OF TOTAL FINANCIAL AID AWARD Monthly WHEN WILL YOUR POSITION END Actual gross income or attach payroll printout for last three months MONTH CURRENT MONTH Tips Yes if yes how often and how much Commissions Bonuses Overtime Work schedule include exact times when possible MONDAY TUESDAY Is Health Insurance available WEDNESDAY THURSDAY FRIDAY SATURDAY If yes is employee enrolled in the health plan When does the coverage begin What is the employee s portion of premiums EMPLOYER/REPRESENTATIVE S SIGNATURE DSHS 14-252 X REV. Section 1 To be filled out by the client/employee. I authorize my employer to release information to the Department of Social and Health Services. EMPLOYEE S SIGNATURE SOCIAL SECURITY NUMBER OPTIONAL EMPLOYEE S NAME EMPLOYEE S JOB TITLE EMPLOYER S ADDRESS DATE EMPLOYEE STARTED WORK Is this a new job No AVERAGE HOURS PER WEEK Pay frequency RATE OF PAY OR SALARY HOURLY DAILY OR PIECE RATE Daily Is this job Work Study Yes DATE FIRST CHECK WAS RECEIVED Weekly Has job ended If yes when Every two weeks why Two times a month IF YES PROVIDE VERIFICATION OF TOTAL FINANCIAL AID AWARD Monthly WHEN WILL YOUR POSITION END Actual gross income or attach payroll printout for last three months MONTH CURRENT MONTH Tips Yes if yes how often and how much Commissions Bonuses Overtime Work schedule include exact times when possible MONDAY TUESDAY Is Health Insurance available WEDNESDAY THURSDAY FRIDAY SATURDAY If yes is employee enrolled in the health plan When does the coverage begin What is the employee s portion of premiums EMPLOYER/REPRESENTATIVE S SIGNATURE DSHS 14-252 X REV. .

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