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assistance.  \nParent signature  \nSection I – General Information  \nName of employee:   SSN:    \nAddress:   Job title:   Type of work performed:   Number of hours/week:   Number of days/week   How often is/was employee paid:   day   week   bi-weekly   monthly Rate of pay: $  per   (hr/day/wk/etc. ) Other   Date current employment began:   Date previously employed   Does/did employee receive tips?   yes   no (if yes, please show tips in Section III)  \nSection II – Loss of Income  \nDate employment ended:   Reason for termination    \nIs the loss of income   Permanent or   temporary? If temporary, when do you expect the employee to return to work?    \nDate employee received final check:   Gross amount  (Please list last 6 weeks of pay in Section III. )  \nWill employee receive any vacation pay, retirement refund, or other?   Yes   No If yes, what type?   Date received   Amount    \nIs employee eligible for any type of benefits from your company, such [as ext. insurance](as ext. insurance)[ ](as ext. insurance)[coverage](coverage) , worker’s compensation , or other?   Yes   No  \nRevised June 2011  \nSection III – Record of Pay Received  \nList the gross amount and dates of checks or cash which were paid for the last 6 weeks in the space below.  \n\n| Pay Period Ending | Date Pay\u003Cbr>Received | Gross Earnings | No. of reg. hours worked | Rate of pay | No. of OT hours | Rate of\u003Cbr>pay for OT | Tips | Earned\u003Cbr>Income Credit |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- |\n|  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |\n\nIf hours or rate of pay has varied in the above period, please state why.    \n\n|  |\n| --- |\n|  |\n\nSection IV – Employer Information  \nI certify that the information given in this form is true and correct to the best of my knowledge. I also acknowledge that the purposeful giving of false information is a prosecutable offense.  \nSignature of Employer Employer’s Title  \nName of Business Telephone Number  \nAddress Date Completed  \nReturn completed form to: Early Learning Coalition of Polk County  \nAttention:    \nRevised June 2011","cbCaicG6bgolWIbD","https://ap.wps.com/l/cbCaicG6bgolWIbD","pdf",77997,"English","# Section I – General Information\n## Name, job, work schedule, and pay frequency\n# Section II – Loss of Income\n## Termination date, reason, final check, and benefits\n# Section III – Record of Pay Received\n## Last 6 weeks gross pay and work hours\n# Section IV – Employer Information\n## Certification, employer signature, and return instructions","[{\"question\":\"Who provides permission to release information, and for what purpose?\",\"answer\":\"The parent/guardian provides permission for the employer to release employment and income details to the Early Learning Coalition of Polk County to determine childcare assistance eligibility.\"},{\"question\":\"What does the form require under Loss of Income?\",\"answer\":\"It requests the employment end date, reason for termination, whether income loss is permanent or temporary, the date of the final check and gross amount, and whether vacation pay, retirement refunds, or other payments were received.\"},{\"question\":\"What information must the employer record in the last 6 weeks pay table?\",\"answer\":\"For each pay period, the employer lists the pay period ending date, date pay was received, gross earnings, regular hours worked, pay rate, overtime hours and OT rate, tips, and earned income credit, plus an explanation if hours or rates varied.\"}]","Verification of Employment Loss of Income - Form | PDF",1789503508]