VERIFICATION OF EMPLOYMENT AND LOSS OF INCOME FORM 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin with SECTION 1 – GENERAL INFORMATION. Fill in the employee's name, Social Security number, and address. Provide job title, type of work performed, and details about hours and pay frequency.
3. Complete the payment details including rate of pay and number of dependents claimed. Indicate if the employee is on company payroll or self-employed.
4. In SECTION 2 – LOSS OF INCOME, provide the employer's name and termination date. State the reason for termination and whether the loss of income is permanent or temporary.
5. SECTION 3 – VERIFICATION OF EMPLOYMENT requires listing gross amounts paid within the last six weeks. Include dates received and any tips earned.
6. Finally, complete SECTION 4 – EMPLOYER INFORMATION by certifying that all information is accurate. Ensure to sign and print your name along with business details.

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