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Get NY DOH-5017 2010-2022

Programs Verification of Employment Name: App. Reg/Case #: Social Security Number: XXX-XXAddress: STREET CITY STATE ZIP CODE To be completed by the employer: I certify that works for me as The employee is paid (check one) (WHAT DOES EMPLOYEE DO?) Weekly Two Weeks Does the employee have access to New York State Health Insurance (NYSHIP)? Yes No Does the employee have dependents enrolled in his/her employer sponsored coverage? Yes Twice per month No Please supply the followin.

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