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To be completed by employer s personnel or payroll department The above named individual is requesting/receiving publicly funded day care services. To make a financial eligibility determination it is necessary to verify income for the last three 3 months. To make a financial eligibility determination it is necessary to verify income for the last three 3 months. Please list overtime if any in the appropriate column* Do NOT include time and leave penalties in the REGULAR GROSS column* Period of E ...

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