STATE OF NEVADADEPARTMENT OF HEALTH AND HUMAN SERVICES

DIVISION OF WELFARE AND SUPPORTIVE SERVICES

STEVE SISOLAKGovernor

RICHARD WHITLEY, MSDirector

STEVE H. FISHERAdministrator

ATTENTION: Payroll Department

TANF MEDICAID SNAP

Date:Case Name:Case ID:

AUTHORIZATION: I authorize you to release tothe Division of Welfare and Supportive Services therequested information.

Client Signature Date

EARNINGS VERIFICATION

Please provide the information for each of the items below and return to the above address. Your cooperation will helpinsure integrity and maintain accountability in the administration of public funds in Nevada. The information provided uswill be used only in conjunction with the official duties of this department and will be considered confidential.

If our identifying information (name, Social Security number or address) does not agree with your records, please indicatethe change.

RE:Name Social Security Number

Employee's Address:

1. Date work Began: Number of Hours employee is scheduled to work per week:

2. Hourly rate of pay $ Average hours worked per week: Date of first paycheck:

3. How often are paychecks issued: Weekly Bi-weekly Semi-monthly Monthly

When are regularly scheduled paydays?

4. Will “tips” be received? YES NO If YES: Estimated amount: $ per

5. Is this employment Contractual? YES NO If YES: Contracted wage amount: $ per

Maximum Earnings provided in contract: $ Number of months covered by this contract:

6. Are/Were wages funded in whole or in part by Workforce Incentive (formerly JTPA?) Programs? YES NO

If YES, through: Work experience OR On-the-job training

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7. Please list below all monies (earnings, sick pay, vacation pay, disability, etc.) PAID or ANTICIPATED TO BE PAID(regardless of when earned to the employee in the month of): undefined

PAY PERIODENDING

HOURS WORKEDPER PAY PERIOD

ACTUALDATES PAID

GROSS WAGES PAID(Include special allowances such

as meals, uniforms, etc., and showa break-out of such amounts)

PRE-TAXDEDUCTIONS(Source/Type)

8. Do you anticipate any change in the number of hours, rate of pay or paydays next month: YES NO

If YES, please explain the change.

9. Is Medical Insurance available to the employee? YES NO If YES, is the employee enrolled? YES NO

If YES, provide the policy # Effective Date: End Date:

Names of dependents covered:

10. If this person is NOT working for you at this time, complete the following information:

DATE

Quit:Fired:Leave of absence:Applied Workers Comp.:

Reason for leaving:Expected date of return:Date of final check: Gross amount: $

Signature of Employer Print Name Title Date Telephone Number

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TANF: OffMEDICAID: OffSNAP: OffDate: Case Name: Case ID: Date Authorized: Name: SSN: Employees Address: Date work Began: Number of Hours employee is scheduled to work per week: Hourly Rate: Average hours worked per week: Date of first paycheck: Payroll Frequency: OffWhen are regularly scheduled paydays: Tips Received: OffTip Amount: Tip Amount Frequency: Contractual employment: OffContracted Wage: Contracted Wage Period: Maximum Earnings: Number of months covered by this contract: Workforce Incentive: OffWorkforce Incentive1: OffPaid Month of: [ ]PPE1: Hours Worked1: Actual Dates Paid1: Gross Wages Paid1: Pre-Tax Deductions1: PPE2: Hours Worked2: Actual Dates Paid2: Gross Wages Paid2: Pre-Tax Deductions2: PPE3: Hours Worked3: Actual Dates Paid3: Gross Wages Paid3: Pre-Tax Deductions3: PPE4: Hours Worked4: Actual Dates Paid4: Gross Wages Paid4: Pre-Tax Deductions4: 8: Off9a: Off9b: OffPolicy#: Effective Date: End Date: Names of dependents covered: Quit: Fired: Reason for Leaving: Leave of Absence: Expected Date of Return: Applied Workers Comp: Date of final check: Gross Amount: Print Name1: Title: Date Signed: Telephone Number1: If yes explain: