THIS SECTION TO BE COMPLETED BY OWNER AND EXECUTED BY TENANT
TO: (Name & address of employer) Date:
Applicant/Tenant Name Social Security Number Unit # (if Applicable)
I hereby authorize release of my employment Information.
Signature of Applicant / Tenant
The individual named directly above has applied to rent a housing dwelling within Maricopa County. Per the Arizona State Landlord Tenant Act we are allowed by law verification of employment and income in order to determine the anticipated gross income for the next twelve months to help with our decision to rent to applicant. The information provided will remain confidential and private and used for said purpose only. Your prompt response is crucial and greatly appreciated.
FAX THIS FORM TO:
THIS SECTION TO BE COMPLETED BY EMPLOYER
Employee Name: ___________________________________________ Presently Employed: Yes ____ Job Title: _______________________________________________ No_____ Last Day of Employment _______________ semi-monthly monthly yearly other
Date First Employed ___________________ (circle one) per hourly weekly bi-weekly
Current Wages/Salary: $ __________
Average # of regular hours per week: ___________________ Year-to-date earnings: $___________________
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: $_____ (circle one) per 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): __________________________________________________ Is employee eligible for unemployment compensation?____ Yes ____ No If yes, how long? ________________ How much? _____________ Additional remarks: ____________________________________________________________________________________________________ _______________________________________
Employer's Printed Name
Employer [Company] Name and Address
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.