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Earned income verification request form

Nebraska dhhs forms 2025

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The document is an Earned Income Verification Request form from the Department of Health and Human Services, intended for clients to authorize their employers to provide employment and income information. It includes sections for employer details, employment dates, pay rates, benefits, and wage information for recent pay periods. The form must be completed and signed by both the client and employer before submission.

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Click ‘Get Form’ to open the Earned Income Verification Request in the editor.
Begin by entering your employer's name and address in the designated fields. This information is crucial for verifying your employment.
Sign the form where indicated, authorizing your employer to release your employment information to DHHS. Don't forget to include your Social Security Number (SSN) and the date.
Next, have your employer complete their section. They will need to provide details such as the start date of employment, pay rate, and estimated hours scheduled per week.
Ensure that your employer circles how often pay is received and provides any additional pay information, including tips or bonuses.
For terminated employment, make sure they fill out the relevant sections regarding the reason for termination and final paycheck details.
Finally, ensure that your employer signs the form and includes their contact information for verification purposes before submitting it back to DHHS.

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How do I contact DHHs Medicaid in Nebraska?

There are Many Ways to Apply for Medicaid: Phone lines are open from 8:00 a.m. to 5:00 p.m. Monday through Friday. (855) 632-7633. In Lincoln: (402) 473-7000. In Omaha: (402) 595-1178.

How do I check the status of my Medicaid in Nebraska?

Call the Medicaid claims customer service at (877) 255-3092 or (402) 471-9128. Provide the Medicaid claim number (if you have it) or your 11-digit Medicaid provider number, the clients 11-digit Medicaid ID number and the claim date of service.

What is documentation required for Medicaid in Nebraska?

Clients can also contact DHHS for assistance via: Economic Assistance 800-383-4278. Medicaid 855-632-7633. AccessNebraska.ne.gov

What is the phone number for access Nebraska food stamps?

Report to the agency if you have changed your address, phone number, or email address. Submit an online change report or contact ACCESSNebraska at (855) 632-7633 to speak to a representative.

What is the number for DHHS benefits in Nebraska?

Our SNAP Outreach team can help families and individuals apply over the phone in as little as 15 minutes. Nebraska residents can call 1-855-444-5556 and Iowa residents can call 1-855-944-3663 to get started.

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How do I renew my food stamps in Nebraska?

You can renew your benefits online with an ACCESS Nebraska account. If youd rather renew in person, call your caseworker, local office, or the Nebraska SNAP hotline (1-800-383-4278) to find out how.