Employer statement form 2026

1. Click ‘Get Form’ to open the employer statement form in the editor.
2. Begin by entering the Employer's Name and Address at the top of the form. This information is crucial for identifying the employer.
3. Fill in the Date field to indicate when you are completing the form.
4. If applicable, enter the Employee's SSN. Note that this field is optional but may be necessary for processing.
5. Provide the All Kids/FamilyCare Applicant's Name, which refers to the employee applying for medical coverage.
6. Indicate how frequently the employee is paid by selecting one of the options: Weekly, Every 2 weeks, Twice a month, or Monthly.
7. Specify the Hours worked per week by entering a numerical value in the designated field.
8. Complete the section regarding pay details by providing information on PAY PERIOD (beginning and end date), PAY DATE (when check was received), and GROSS PAY (excluding Earned Income Credit).
9. Certify that all provided information is correct by signing and dating at the bottom of the form. Include your title and phone number for any follow-up inquiries.

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