Sample
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WAGE VERIFICATION FORM
Requesting Party
Name [REQUESTOR NAME] Phone [PHONE #]
Address [ADDRESS]
E-Mail [EMAIL] Fax [FAX #]
Employee Consent
I, [EMPLOYEE NAME], authorize and hold harmless of any legal and financial liability my employer to release to the requesting party listed above. I understand that this information may be verified by phone, fax, or e-mail.
Signature ________________________ Date [MM/DD/YYYY] Print [EMPLOYEE NAME]
TO BE COMPLETED BY THE EMPLOYER ONLY
Employee Job Title: [EMPLOYEE TITLE] Start Date: [MM/DD/YYYY]
On Leave? ☐Yes ☐No
If “yes,” type of leave: [LEAVE TYPE]
If “yes,” return date: [MM/DD/YYYY]
Monthly Average
Hourly Pay: $[#] Commission: $[#] Tips: $[#]
Pay Period: ☐ Weekly ☐ Bi-Weekly ☐ Monthly Paid in Cash? ☐ Yes ☐ No
How many hours per week does the employee work? [#]
Do Hours Vary? ☐Yes ☐No
If Yes, Explain: [DESCRIPTION]
EMPLOYER CERTIFICATION
Employer / Company Name: [EMPLOYER NAME]
Address: [ADDRESS]
Phone: [PHONE #] E-Mail: [EMAIL]
I certify that the information listed above is true and accurate to the best of my knowledge.
Signature ________________________ Date: [MM/DD/YYYY]
Print: [EMPLOYER NAME]
Title: [EMPLOYER TITLE]
Most Common Use of the Form
A wage verification form is commonly used when calculating how much a spouse has to pay for child support. It may also be used for disability compensation, financial assistance, rental applications, or any other situation that requires confirmation of a person’s position and wage.
Using the Form
The following steps should be followed when using a wage verification form:
- The person or organization requesting verification enters their contact information in the Requesting Party section at the top of the form.
- The employee completes and signs the Employee Consent section.
- The form is sent to the employer to complete.
- The employer fills out the rest of the form.
- The employer signs the form and returns it to the requesting party.