OKDHS Employment Verification

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                  [Sender name and address]

                               Employment Verification
                                            Client name:
                                            Case number:
                                            County number:
[Recipient name and address]

Please give to OKDHS any information requested from your records concerning
my employment.

                                      Client, guardian, or parent

                               Witness signature, if client signs by mark

          Witness address

To determine eligibility for benefits from OKDHS, it is necessary to have information
regarding the employment status of                           , Social Security number
                            , during the period beginning                 and ending
Please complete the information on pages 3 and 4 of this form and sign on the line
indicated by the X. This form must be returned to the OKDHS human services center
indicated above. A postage-paid, self-addressed envelope is enclosed for your use.
Your cooperation in supplying this information is appreciated.

 Name and title                                                     Phone number

                                                                    FAX number

Revised 9-1-2007                        08AD094E (ADM-94)                        Page 1 of 4
08AD094E (ADM-94)                                   Employment Verification

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Page 2 of 4                                               Revised 9-1-2007
08AD094E (ADM-94)                                                   Employment Verification

Client name:                                                     Case number:
1. Date employment started:
   Date first pay was or is to be received:
   Number of hours in first paycheck:
   Gross amount (before taxes) of first paycheck:
   Is the first paycheck for a full pay period?   Yes       No
2. Number of hours worked in a regular work week:
   Hourly pay rate:
   Overtime hourly pay rate:
   If hours vary, please explain:
3. Check how often paid and show when paid:
   • Monthly, date paid:
   • Every two weeks, day paid:
   • Twice monthly, dates paid:
   • Weekly, day paid:
   • Daily
4. Check which days the employee is scheduled to work. Show start and stop times:
Sun        Mon          Tues        Wed         Thu         Fri          Sat
Start:     Start:       Start:      Start:      Start:      Start:       Start:

Stop:          Stop:       Stop:          Stop:         Stop:       Stop:        Stop:

Below, please provide the requested information for each paycheck received by this
employee for the months of                through                .
  Date      Gross      Payroll              Café    Uniform
received   amount      period    Hourly    allow-    allow-      Tips    Over-     Bonuses
 check        of        dates    wage      ance      ance                time

5. Does the employee have health insurance coverage?                     Yes     No
   If yes, give name of company, policy number, type of coverage, persons covered, and
   effective date.

Revised 9-1-2007                                                                 Page 3 of 4
08AD094E (ADM-94)                                                  Employment Verification

6. Is the employee required to have health insurance coverage?                 Yes      No
7. Is employment subsidized, such as Workforce Investment Act (WIA)? Yes                No
   If yes, please explain:
    a. If employment has been terminated, please provide the information listed below:
       •   Date employment terminated:
       •   Total gross income (before taxes) received in last month of employment:

       •   Gross amount (before taxes) and date of receipt of final paycheck:

           Reason for termination:                                      Quit         Fired

    b. Is employee eligible for benefits listed below?                        Yes      No
    c. If yes, please check.
       Unemployment            Workers' Compensation              Time loss
       Insurance               Paid accrued leave

     Print name of employer       Print name of work site supervisor    Date

               Authorized signature of employer and title               Phone number

Page 4 of 4                                                              Revised 9-1-2007