SWOJFS 2775 (REV. 10-12) Page 1 of 2 (SWOJFS 3)
Southwest Ohio
County Departments of
Job & Family Services
County Agency: Hamilton County Job & Family Services
Address: 222 E. Central Parkway, Cincinnati, OH 45202
Phone: (513) 946-1000
Fax: (513) 946-1076
Website: www.hcjfs.org
Employment Verification Request
JFS Worker:
Phone:
Date:
Return by:
Employer Name:
Employee Name:
Employer Address:
Social Security Number:
City:
State:
Zip:
Case Number:
By applying for CDJFS programs, the individual has agreed that the CDJFS may contact other persons or organizations to obtain the necessary proof of eligibility
and level of assistance. In addition, Ohio Revised Code 5101.37 authorizes the CDJFS to make investigations that are necessary in the performance of their duties.
Authorization for Release of Information
I agree that the employer named below may release my employment information to Hamilton County Job & Family Services & the Cincinnati Metropolitan
Housing Authority.
This information will be used to determine eligibility for: Cash Assistance;
Food Assistance; Medical Assistance; Other, specify: .
I am aware of my responsibilities to report completely and fully all facts which bear upon my eligibility for assistance. I realize if the requested information
reveals I have improperly reported my situation, the information may be given to the prosecuting attorney for possible civil action or criminal prosecution.
Signature of Applicant/Recipient: Date:
Employer to Complete
Dates of Employment
Corporate Name:
If employment has ended, also complete this section.
Name of Employment Site:
Last Day Worked:
Date Last Pay Received:
Type of Separation:
First Day Worked:
Laid Off Illness or Injury
No Call or Show Other (specify): ____________________
Resignation Eligible for Post-Employment Benefits (specify):
Discharged
Date First Pay Received:
List interruption or leave period during employment.
From Date: To Date:
Strike Start Date:
Strike End Date:
Effective Lockout Date:
Rate/Hours/Pay Frequency
Current Hourly Rate:
Day of Week Paid:
Pay Period Frequency:
Weekly Twice Monthly
Biweekly Other (Specify) __
Overtime is:
Not expected to be worked in the future
Worked routinely monthly
Number of set hours to work per Week: ; OR Number of hours will vary from __________ to __________ per Week
Wages (Last 6 Pays)
Period Ending
Date
Received
Hours
Hourly
Rate
Gross Pay
Without Tips, Bonus
or Commission
Tips
Bonus or
Commission
Garnishment
Child Support
Deduction
Health Insurance
Is the employee or their dependents enrolled in health insurance?
No Yes
Begin Date: End Date: Policy Number: Group Number:
Name/Address of Insurance Company:
List Covered Members:
Additional Information Needed For Time Period Below (See Reverse only if Time Period is Noted Below)
Time Period Requested – From Date: To Date:
Employer Signature
Employer Representative Signature:
Title: Phone: FAX: Date:
SWOJFS 2775 (REV. 10-12) Page 2 of 2 (SWOJFS 3)
Employee Name:
Employee Social Security Number:
If indicated on the front side, complete the following information for the time period indicated on page 1 of this
form. If it is more convenient or you need more space, please substitute copies of the employee’s payroll records.
Date Pay
Received
Gross Pay Without Tips,
Bonus or Commission
Tips
Bonus or
Commission
Garnishment
Child Support
Deduction
Other Information Requested
Requested Information:
Employer Response to Requested Information:
Employer Signature
Employer Representative Signature:
Title:
Date:
Phone:
FAX:
