Free Wage Verification Form | PDF

A wage verification form is sent to an individual’s employer to get information about their income and employment status. The form will ask the employer to relay the employee’s position, average pay, and duration of employment. The form also features the employee’s signed authorization, removing any liability from the employer for releasing information.

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.

Wage Verification Form