Form 128 Employment Verification - Health Center of Southeast Texas 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the date at the top of the form. Next, fill in the employer's name and address, ensuring accuracy for proper communication.
3. Provide the case record number and company name, along with the office address and telephone number. This information is crucial for identification purposes.
4. In the employee section, input the employee's name and address as per your records. Confirm their employment status by selecting 'Yes' or 'No' regarding their current employment.
5. Indicate whether FICA or FIT is withheld from their pay. If applicable, provide details on their rate of pay and average hours worked per pay period.
6. Complete the wage chart by listing all wages received during specified months, including any bonuses or additional payments. Use the comments section to clarify any 'Other Pay' details.
7. If applicable, note any leave without pay dates and provide information about health insurance availability for the employee.
8. Finally, ensure that a signature and title are included at the bottom of the form along with your contact information before submitting it back to your employee or via fax.

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