VERIFICATION OF EMPLOYMENT/ LOSS OF INCOME FORM - Form 3022 - Employer Instructions

Sep 15, 2026

Uploaded by Putri

Verification of Employment/Loss of Income Form 3022 collects employer-completed details needed to determine an individual’s eligibility for child care services. The form requires legible employer entry, including loss of income status (temporary or permanent), anticipated return-to-work and potential compensation during leave. It also requests four consecutive weeks of income data, work schedule, hours, pay frequency, overtime and tip eligibility, plus employer contact and a signed certification. False information may trigger investigation under Florida statutes.

LanguageEnglish

CategoryForms

FormatPDF

Pages1

AccessFree to download

SECTION 1: LOSS OF INCOME

SECTION 2: EMPLOYEE INFORMATION

SECTION 3: EMPLOYER INFORMATION

VERIFICATION OF EMPLOYMENT/ LOSS OF INCOME FORM 3FORM022 Instructions: TO BE COMPLETED ENTIRELY, SIGNED, AND DATED BY EMPLOYER. Please print legibly, do not use white-out on this form, and initial changes. In order to determine the eligibility of the individual listed for child care services, assist by answering the questions below. Information will be verified by Coalition Eligibility staff. | Employee Name (Last, First, Middle Initial) | Job Title: | Current Employment Start Date: | | --- | --- | --- | SECTION 1: LOSS OF INCOME | Last date of employment, if applicable: | | | --- | --- | | Is the loss of income
􀂅 Temporary 􀂅 Permanent | If temporary, when do you expect the employee to return to work? | | If temporary, will the employee be eligible for any type of compensation during their leave?
􀂅 Yes 􀂅 No | If yes, what type?
Amount $
Frequency: | SECTION 2: EMPLOYEE INFORMATION Income Information is to reflect four (4) weeks current and consecutive pay | DATE PAY RECEIVED
(List Most Recent Pay) | GROSS EARNINGS BEFORE ANY DEDUCTIONS (Includes Overtime, Shift Differential, Tips, Etc.) | NUMBER OF HOURS WORKED | | --- | --- | --- | | 1. | | | | 2. | | | | 3. | | | | 4. | | | | Days Worked:
􀂅 Monday 􀂅Tuesday 􀂅 Wednesday 􀂅Thursday 􀂅 Friday 􀂅 Saturday 􀂅 Sunday | | | | | --- | --- | --- | --- | | Work Schedule: | From
􀂅 a.m. 􀂅 p.m. | To
􀂅 a.m. 􀂅 p.m. | or Varied Hours | | Hourly Rate: | | \# Hours/Week: | | | Pay Frequency: 􀂅 Weekly 􀂅 Bi-Weekly 􀂅 Semi-Monthly 􀂅 Monthly | | | | | Eligible for overtime? 􀂅Yes 􀂅 No | | If yes, how frequently is overtime worked? | | | Eligible for tips, commissions, bonus pay, or shift differential? 􀂅Yes 􀂅 No | | | If yes, how frequently? | | Is employment seasonal? 􀂅Yes 􀂅 No | | If yes, season begins season ends | | SECTION 3: EMPLOYER INFORMATION | Company Name | Address | Telephone Number | | --- | --- | --- | By my signature below I certify that the information given is true and complete. I understand that it is against the law to give false information or assist someone else to receive benefits under false pretense. These actions could result in termination of further services and possible referral to the Department of Financial Services, Public Assistance Fraud Division for further investigation, pursuant to Chapter 414.39, Florida Statutes. Under penalty of perjury, I declare that I have read the above information and that the facts stated are true. | Employer (Print Name) | Employer’s Title | Employer’s Signature | Date | | --- | --- | --- | --- | Form 3022 (2023)

FAQs

Who must complete, sign, and date the form?

The employer must complete the form entirely and provide signature and date.

What information is required to document loss of income?

The form collects the last date of employment (if applicable) and whether the loss of income is temporary or permanent, including return-to-work timing and whether compensation is provided during leave.

What income and work details does the form request for eligibility review?

It requires gross earnings before deductions and hours worked for the most recent four consecutive pay periods, plus days worked, work schedule, pay frequency, overtime eligibility, and whether tips/commissions/bonuses/shift differentials apply.

Sep 15, 2026

Uploaded by Putri