[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-277739-105":53,"doc-detail-277739-en":127},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":120,"head_meta":122,"extra_data":124,"updated_unix":126},105,"en","employmentloss-of-income-verification-form","Employment/Loss of Income Verification Form","","Employment/Loss of Income Verification Form collects employer-provided details needed to determine eligibility for public assistance. It gathers general employment information (job role, work schedule, pay frequency and rate, health insurance, dependents, and payroll savings participation), documents the loss of income event (end date, termination reason, permanence, final paycheck and related payments), and records the last four weeks of pay (check/cash dates, gross earnings, regular and overtime hours, rates, tips, and EIC). The employer attests to the accuracy with a signature and completion date.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/employmentloss-of-income-verification-form/277739/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/employmentloss-of-income-verification-form/277739.png","ImageObject",442,249,{"name":88,"@type":89},"Dozel","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-26","2026-09-15",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",10,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"What information is requested in Section I (General Information)?","Question",{"text":109,"@type":110},"Section I requests the employee’s name, address, social security number, job title, hours and days worked, pay frequency and rate, tips, whether employment is seasonal, health insurance coverage, dependents, and any payroll savings/profit sharing participation.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"How does Section II document the loss of income?",{"text":114,"@type":110},"Section II records the employment end date, reason for termination, whether the income loss is permanent or temporary (and expected return date if temporary), the final check date and gross amount, and whether vacation pay, retirement refunds, or other payments or benefits apply.",{"name":116,"@type":107,"acceptedAnswer":117},"What details are required in Section III (Record of Pay Received)?",{"text":118,"@type":110},"Section III requires listing the gross amounts and pay received dates for the last four weeks, including regular and overtime hours and rates, tips, and earned income credit (EIC). If hours or pay varied, an explanation is requested.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},277739,1789503509,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":126,"read_time":9},962085662650,"https://ap-avatar.wpscdn.com/davatar_29158cc5080c5b710cf443261637dec0","VERIFICATION OF EMPLOYMENT/LOSS OF INCOME  \nNOTE: Use the \"tab\" key to move to the next field. Date:________________________  \nClear  \n\n|  |\n| --- |\n|  |\n\nIn order to determine the eligibility of   for public assistance, please assist us by answering the questions below and returning this form to us by    \nCase Name  \nCase Number/Cat/Seq.  \nOffice Address / Phone Number:  \nPlease complete each section which has been marked on Page 1 AND Page 2 of this form.  Section I – GENERAL INFORMATION  \n1. Name of Employee:  *Social Security Number:  Address:   \n2. Job Title:  Type of Work Performed:   \n3. Number of Hours Worked Per Week:  Number of Days Worked Per Week:   \n4. A. How often is/was the employee paid?  Day  Week  Bi-Weekly  Monthly  \nB. Rate of pay: $  per    Other   Hr. /Day/Wk . /etc . (Explain)  \n5. Date current employment began:  Date previously employed:   \n6. Does/did employee receive tips?  Yes  No (If yes, please show tips in Section III.)  \n7. Is/was employment seasonal?  Yes  No If yes, season begins:  ends:   \n8. Is/was the employee covered by health insurance?  Yes  No  \nIf yes, name of insurance company:   \n9. Number of dependents covered:   \n10. Does/did the employee participate in any type of payroll savings plan or profit sharing?  Yes  No If yes, what is the balance? $   \n11. Does the person perform their job duties:  in their home  in your home  N/A  \n Section II – LOSS OF INCOME  \n1. Date employment ended:   \n2. Reason for termination:   \n3. Is the loss of income  Permanent or  Temporary? If temporary, when do you expect the employee to return to work?    \n4. Date employee received final check:  Gross amount: $   \n(Please list last 4 weeks in Section III.)  \n5. Will employee receive any vacation pay, retirement refund, or other?  Yes  No  \nIf yes, what type?   Date received:  Amount: $   \n6. Is employee eligible for any type of benefits from your company, such as extended insurance coverage, workers’compensation, or other?  Yes  No If yes:  \nA. Name of insurance company:   \nB. Reason for benefits:   \nCF-ES 2620, PDF 05/2010 [65A-1 . 205, F . A . C . ] Page 1 of 2  \nCase Name Case Number/Cat/Seq.  \n Section III – RECORD OF PAY RECEIVED  \n\n| List the gross amounts and dates of checks or cash, which were paid for the last four weeks in the space below. |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| Pay Period Ending | Date Pay Received | GROSS Earnings | No . of\u003Cbr>Regular\u003Cbr>Hours\u003Cbr>Worked | Rate of Pay | No . of\u003Cbr>Overtime\u003Cbr>Hours | Rate of Pay for\u003Cbr>Overtime | Tips $$ | Earned Income\u003Cbr>Credit (EIC) |\n|  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |\n| If hours or rate of pay has varied in the above period, please state why. |  |  |  |  |  |  |  |  |\n\nSection IV – EMPLOYER INFORMATION  \nGo Back To Page One  \n\n| What I have written on this form is true to the best of my knowledge. I know that if I give false information on purpose, I may be subject to prosecution for fraud. |\n| --- |\n| Signature of Employer Name of Business Address\u003Cbr>Employer’s Title Telephone Number If applicable, enter \"ext.\"and extension number\u003Cbr>Date Completed |\n\nCF-ES 2620, PDF 05/2010 Page 2 of 2","cbCainwGCdCGOZdX","https://ap.wps.com/l/cbCainwGCdCGOZdX","pdf",220591,"English","# Section I - General Information\n# Section II - Loss of Income\n# Section III - Record of Pay Received\n# Section IV - Employer Information","[{\"question\":\"What information is requested in Section I (General Information)?\",\"answer\":\"Section I requests the employee’s name, address, social security number, job title, hours and days worked, pay frequency and rate, tips, whether employment is seasonal, health insurance coverage, dependents, and any payroll savings/profit sharing participation.\"},{\"question\":\"How does Section II document the loss of income?\",\"answer\":\"Section II records the employment end date, reason for termination, whether the income loss is permanent or temporary (and expected return date if temporary), the final check date and gross amount, and whether vacation pay, retirement refunds, or other payments or benefits apply.\"},{\"question\":\"What details are required in Section III (Record of Pay Received)?\",\"answer\":\"Section III requires listing the gross amounts and pay received dates for the last four weeks, including regular and overtime hours and rates, tips, and earned income credit (EIC). If hours or pay varied, an explanation is requested.\"}]","Employment/Loss of Income Verification Form | PDF"]