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This information will be used only to determine the eligibility status and level of household benefit. Complete only the selected section below that includes an authorization to release information.\u003Cbr>Please return this form to:\u003Cbr>Name & Title:   Phone:  \u003Cbr>Address:   Fax:  \u003Cbr>Email:   |\n| --- |\n|  Employment Income\u003Cbr>\u003Cbr>ESG Applicant Release: I hereby authorize the release of the following employment information.\u003Cbr>ESG Applicant Signature:   Date:  \u003Cbr>Employer representative to complete this section:\u003Cbr>The person named above is employed by   since   He/she is\u003Cbr>paid $   on a   basis and is currently working an average of   hours per   .\u003Cbr>Additional compensation please specify (if any):  Probability of continued employment:  \u003Cbr>Authorized Employer Representative Signature:   Date:  Name, Title:   Address and Phone:   |\n\n Payments and/or Benefit Income (complete one form for each distinct source of income for each adult member of household and attach supporting evidence to this form in case file)  \nCIRCLE ONE: 􀂅Social Security/SSI 􀂅Pension/Retirement 􀂅 TANF  \n􀂅Public Assistance 􀂅Unemployment Compensation 􀂅Workers Compensation  \n􀂅Alimony Payments 􀂅 Foster Care Payments 􀂅Child Support Payments  \n􀂅Armed Forces Income  \n􀂅Other (pls. specify):    \nESG Applicant Release: I hereby authorize the release of the following payment and/or benefit information.  \nESG Applicant Signature:   Date:    \nPayment source representative to complete this section:  \nPayments or benefits in the amount of $   are paid on a   basis. The expected duration of the payments or benefits is    \nAuthorized Payment Source Representative Signature:   Date:  Name, Title:   Address and Phone:","cbCaisupp1lIU3nT","https://ap.wps.com/l/cbCaisupp1lIU3nT","pdf",86982,"English","# Employment Income\n## ESG Applicant Release\n## Employer Verification Section\n# Payments and Benefit Income\n## Payment Source Selection\n## Payment Details Certification","[{\"question\":\"What is the purpose of this form?\",\"answer\":\"The form is used to certify an applicant's income to determine their eligibility status and the level of household benefits for the ESG program.\"},{\"question\":\"Who is responsible for completing the employment section?\",\"answer\":\"The employer or a representative of the payment source must complete the relevant section after the ESG applicant has signed the authorization to release information.\"},{\"question\":\"What types of benefit income can be verified with this form?\",\"answer\":\"The form covers various income sources, including Social Security/SSI, pension or retirement, TANF, public assistance, unemployment compensation, workers' compensation, alimony, foster care payments, child support, and armed forces income.\"}]","ESG Income Verification Form - 2020 | PDF",1789630111]