Form F-10146 "Employer Verification of Earnings" - Wisconsin

What Is Form F-10146?

This is a legal form that was released by the Wisconsin Department of Health Services - a government authority operating within Wisconsin. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2014;
  • The latest edition provided by the Wisconsin Department of Health Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form F-10146 by clicking the link below or browse more documents and templates provided by the Wisconsin Department of Health Services.

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Download Form F-10146 "Employer Verification of Earnings" - Wisconsin

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EVFE
WISCONSIN DEPARTMENT OF HEALTH SERVICES
Division of Health Care Access and Accountability
F-10146 (09/14)
EMPLOYER VERIFICATION OF EARNINGS
MUST BE COMPLETED BY THE EMPLOYER (Instructions on the back)
Please return this form by:
to
EMPLOYER INFORMATION
EMPLOYEE INFORMATION
SECTION 1 – EMPLOYMENT STATUS
Is the employee listed above currently employed by your company?
Yes
No
If yes complete Section 2.
If “No”, Indicate employment end date
/
/
Reason employment ended
Never Employed
Laid Off
Quit
Strike
Fired
Other
Date of final paycheck:
/
/
Gross pay for final month: $
SECTION 2 – EMPLOYMENT INFORMATION
Start date of employment
/
/
Date first paycheck received
/
/
Employee Type
Temporary
Permanent
Title
Manager
Other
Please provide an estimate of the following wage information for the next 30 days.
Type of Pay
Best Estimate of Hrs
Rate of Pay
Regular Scheduled
Worked Per Week
Per Hour
Work Hours
Regular
$
Overtime
$
Other Shift Pay
$
Weekend /Shift Differential pay
$
Holiday Pay
$
Other
$
Gross Per Pay Period
Salary if not paid hourly
$
Bonus and/or Commissions
$
Cash and/or Tips
$
Frequency of pay
Weekly
Bi-Weekly
Semi-monthly
Monthly
Irregular
SECTION 3 – PRE-TAX DEDUCTION INFORMATION
Does this employee have any of the following pre-tax deductions?
Type
How much is deducted?
How often?
Health insurance premiums
$
Health care savings account
$
Parking and transit cost
$
Group life insurance premiums
$
Retirement contributions
$
$
Flex savings account for child care or other dependent care
SIGNATURE - Employer / Designee
Date
Print Name
Phone
Title
FAX
Employer Comments
EVFE
WISCONSIN DEPARTMENT OF HEALTH SERVICES
Division of Health Care Access and Accountability
F-10146 (09/14)
EMPLOYER VERIFICATION OF EARNINGS
MUST BE COMPLETED BY THE EMPLOYER (Instructions on the back)
Please return this form by:
to
EMPLOYER INFORMATION
EMPLOYEE INFORMATION
SECTION 1 – EMPLOYMENT STATUS
Is the employee listed above currently employed by your company?
Yes
No
If yes complete Section 2.
If “No”, Indicate employment end date
/
/
Reason employment ended
Never Employed
Laid Off
Quit
Strike
Fired
Other
Date of final paycheck:
/
/
Gross pay for final month: $
SECTION 2 – EMPLOYMENT INFORMATION
Start date of employment
/
/
Date first paycheck received
/
/
Employee Type
Temporary
Permanent
Title
Manager
Other
Please provide an estimate of the following wage information for the next 30 days.
Type of Pay
Best Estimate of Hrs
Rate of Pay
Regular Scheduled
Worked Per Week
Per Hour
Work Hours
Regular
$
Overtime
$
Other Shift Pay
$
Weekend /Shift Differential pay
$
Holiday Pay
$
Other
$
Gross Per Pay Period
Salary if not paid hourly
$
Bonus and/or Commissions
$
Cash and/or Tips
$
Frequency of pay
Weekly
Bi-Weekly
Semi-monthly
Monthly
Irregular
SECTION 3 – PRE-TAX DEDUCTION INFORMATION
Does this employee have any of the following pre-tax deductions?
Type
How much is deducted?
How often?
Health insurance premiums
$
Health care savings account
$
Parking and transit cost
$
Group life insurance premiums
$
Retirement contributions
$
$
Flex savings account for child care or other dependent care
SIGNATURE - Employer / Designee
Date
Print Name
Phone
Title
FAX
Employer Comments
EMPLOYER VERIFICATION OF EARNINGS INSTRUCTIONS
F-10146 (09/14)
EMPLOYMENT VERIFICATION OF EARNINGS INSTRUCTIONS
The Department of Children and Families, the Department of Health Services, a county child support agency or
a county department under § 46.215, 46.22 or 46.23, a multicounty consortium, a Wisconsin Works (W-2)
agency, or a tribal governing body may request form any person in this state information it determines
appropriate and necessary for determining or verifying eligibility or benefits for a recipient under any income
maintenance program, W-2, Child Support enforcement or Wisconsin Shares. Unless access to the information
is prohibited or restricted by law, or unless the person has good cause, as determined by the departments in
accordance with federal law and regulations, for refusing to cooperate, the person shall make a good faith effort
to provide the information within 7 days after receiving a request under this paragraph.
We required employment and wage information concerning the employee named on this Employer Verification
of Earnings form. Complete and return the form to the employee as soon as possible so that s/he can return it by
the date indicated.
Review the Federal Employment Identification Number (FEIN) listed on the form. If it is incorrect or
missing, write the correct number on the form, if known.
This form will be scanned. Write clearly using blue or black ink.
Write additional comments in the comments section.
Although it is the employee’s responsibility to return this form to the local agency, in order to expedite this
process, you may return this form to the address or fax number listed. If you do, inform the employee that you
have returned this form.
SECTION 1 - EMPLOYMENT STATUS
If the employee never worked for your company, check the "Never Employed" box. Sign, date and return the
form. If the employee listed on the form is no longer an employee of your company, check the "No" box.
Write in the date the employment ended. Write in the date of the employee’s last paycheck and gross amount
(before any deductions) of pay for his/her final month.
SECTION 2 - EMPLOYMENT INFORMATION
If the employee listed on the form is employed by your company, check the "Yes" box and complete Section
2. Write in the date the employee started working for your company and the date of the employee's first
check.
Employee Type – Check the temporary or permanent box if the employee is in a position that is defined as
permanent by your company.
Employee Title – Check the Manager box if the employee is a manager. Check the Other box if the employee
is not in a position of management as defined by your company.
Please provide your best estimate of gross wages (before any deductions) the employee will earn for the next 30
days.
Best estimate of Weekly Hours – Please provide the hours the employee is expected to work weekly.
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