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  1. Click ‘Get Form’ to open it in the editor.
  2. Begin by filling out the Employee Personal Information section. Enter your full name, residential address, home phone, and email address if known.
  3. In the Employer and Job Information section, indicate your employment status (Currently Employed, Terminated, or Never Employed) and provide details such as your job title and dates of employment.
  4. Complete the Wage Information section by specifying your pay cycle, gross pay per period, and current year-to-date earnings.
  5. If applicable, fill out the Health Insurance section with information about available health insurance for yourself and dependents.
  6. Finally, ensure that the Certification Information is completed by your employer with their name, title, signature, and contact information.

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