 
 
EMPLOYMENT VERIFICATION
THIS SECTION TO BE COMPLETED BY MANAGEMENT AND EXECUTED BY TENANT
| TO: | (Name & address of employer) | Date: | 
|   |   |   | 
|   |   |   | 
|   |   |   | 
RE:
| Applicant/Tenant Name |   | Social Security Number |   | Unit # (if assigned) | 
I hereby authorize release of my employment information.
| Signature of Applicant/Tenant |   | Date | 
The individual named directly above is an applicant/tenant of a housing program that requires verification of income. The information provided will remain confidential to satisfaction of that stated purpose only. Your prompt response is crucial and greatly appreciated.
______________________________________
Project Owner/Management Agent
Return Form To:
THIS SECTION TO BE COMPLETED BY EMPLOYER
| Employee Name: |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   | Job Title: |   |   |   |   |   |   |   |   | 
| Presently Employed: | Yes |   |   |   | Date First Employed |   |   |   |   |   | No |   | Last Day of Employment |   | 
| Current Wages/Salary: $ |   |   |   |   |   |   |   |   | (check one) |   |   |   |   |   |   |   |   |   |   |   |   |   |   | 
| □ hourly | □ weekly | □ bi-weekly | □ semi-monthly | □ monthly | □ yearly | □ other | 
| Average # of regular hours per week: |   |   |   | Year-to-date earnings: $______________ from: ____/____/______ through: ____/____/______ | 
| Overtime Rate: $ |   |   |   |   |   | per hour |   |   |   |   |   | Average # of overtime hours per week: |   |   | 
| Shift Differential Rate: $ |   |   |   |   |   | per hour | Average # of shift differential hours per week: |   |   | 
| Commissions, bonuses, tips, other: $ |   |   |   |   | (check one) |   |   |   |   |   |   |   |   |   |   |   | 
| □ hourly | □ weekly | □ bi-weekly | □ semi-monthly | □ monthly | □ yearly | □ other_________________________________ | 
| List any anticipated change in the employee's rate of pay within the next 12 months: |   |   |   |   | ; Effective date: |   | 
If the employee's work is seasonal or sporadic, please indicate the layoff period(s):
Additional remarks:
| Employer's Signature |   | Employer's Printed Name |   | Date |   | 
|   |   |   |   |   |   | 
|   |   | Employer [Company] Name and Address |   |   |   | 
|   |   |   |   |   |   | 
| Phone # |   | Fax # |   | E-mail |   | 
|   |   |   |   |   |   | 
|   |   |   |   |   |   | 
NOTE: Section 1001 of Title 18 of the U.S. Code makes it a criminal offense to make willful false statements or misrepresentations to any Department or Agency of the United States as to any matter within its jurisdiction.
 
Employment Verification (March 2009)