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Get OH HCJFS 3050 - Hamilton County 2010-2024

Name and position print Signature Date Section E I authorize release of the above information to HCJFS. Employee Signature HCJFS 3050 REV. This form can be used for new employment for clarification or if you are returning from a leave of absence. Employment verification must be signed by the employer and be no more than six weeks old. Dear Employer Please complete Sections A D below so that we may determine whether this employee is eligible for child care services. Return to the address checked below. We appreciate your cooperation. HCJFS Child Care Services 222 E. Central Parkway Cincinnati OH 45202 ATTN Fax 513 946 - 1830 Section A Employer Information Company Name Address City/State/Zip code Phone Fax Number Employee Name SSN Date of Hire Is this person on Leave of Absence Yes Still Employed If No Last Date of Employment Scheduled return date Does your company issue pay stubs Pay frequency Hourly Pay Rate Hours paid/week Does employee work overtime No Weekly Bi-weekly Monthly Semi-monthly of OT hours/week OT hourly rate Indicate the Gross income of last 4 pay stubs Pay date If yes what is the weekly amount Does the employee receive tips Section C Schedule Information Sun Mon Earliest Start Time Latest End Time Hours at work Tues Wed Number of days worked/week Thurs Fri Sat Are hours fixed or varied Section D A signature is required and indicates the information is correct to the best of my knowledge. Hamilton County JFS Child Care Services Employment Verification Form Dear Consumer If you have been employed for more than one month please provide one month of current pay stubs as verification of your employment. This form can be used for new employment for clarification or if you are returning from a leave of absence. Employment verification must be signed by the employer and be no more than six weeks old. Dear Employer Please complete Sections A D below so that we may determine whether this employee is eligible for child care services. Return to the address checked below. We appreciate your cooperation* HCJFS Child Care Services 222 E* Central Parkway Cincinnati OH 45202 ATTN Fax 513 946 - 1830 Section A Employer Information Company Name Address City/State/Zip code Phone Fax Number Employee Name SSN Date of Hire Is this person on Leave of Absence Yes Still Employed If No Last Date of Employment Scheduled return date Does your company issue pay stubs Pay frequency Hourly Pay Rate Hours paid/week Does employee work overtime No Weekly Bi-weekly Monthly Semi-monthly of OT hours/week OT hourly rate Indicate the Gross income of last 4 pay stubs Pay date If yes what is the weekly amount Does the employee receive tips Section C Schedule Information Sun Mon Earliest Start Time Latest End Time Hours at work Tues Wed Number of days worked/week Thurs Fri Sat Are hours fixed or varied Section D A signature is required and indicates the information is correct to the best of my knowledge. Hamilton County JFS Child Care Services Employment Verification Form Dear Consumer If you have been employed for more than one month please provide one month of current pay stubs as verification of your employment. This form can be used for new employment for clarification or if you are returning from a leave of absence. .

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