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Click ‘Get Form’ to open it in the editor.
Begin by entering the caseworker's name, office address, and telephone number at the top of the form. This information is crucial for processing your application.
Fill in the employee's name and address accurately as shown on their records. Ensure that all details are correct to avoid any delays.
Indicate whether the individual is currently employed by you by selecting 'Yes' or 'No'. If yes, specify the type of job and employment status (full-time, part-time, etc.).
Provide details about payment frequency and average hours worked per pay period. Include any additional compensation such as overtime pay or bonuses.
Complete the section regarding health insurance availability and enrollment status if applicable.
List all wages received during specified months in the provided chart, ensuring accuracy in gross pay and other payments.
Finally, verify all information entered is true and correct before signing and dating the form. You can then submit it via mail or fax as instructed.
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