Form HW0411 "Work Verification Form" - Idaho

What Is Form HW0411?

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

Form Details:

  • Released on April 13, 2016;
  • The latest edition provided by the Idaho Department of Health and Welfare;
  • 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 HW0411 by clicking the link below or browse more documents and templates provided by the Idaho Department of Health and Welfare.

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Download Form HW0411 "Work Verification Form" - Idaho

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Rev. 4/13/2016 | HW0411
Only your employer or payroll clerk may complete and sign this form.
How to use this form
1. Send the completed form to the Department by mail, fax, or email.
2. Contact us if you or your employer have questions about the form.
Contact the Department
Mail: PO Box 83720 Boise, ID 83720-0026
Phone: 1-877-456-1233
Fax: 1-866-434-8278
E-mail: MyBenefits@dhw.idaho.gov
Employee Information (Please print)
Name of Employee:
Social Security Number:
Wage Information
Date Employee Started:
$
Hourly Pay
Average number of hours per week:
Per hour
$
Monthly Salary
Per month Number of days worked per week:
$
Other
Per:
Other Income
Employee receives (mark all that apply):
Type
Tip
Housing/Utilities
Commissions
Bonuses
Overtime
$
$
$
$
$
Amount
How often?
Is overtime anticipated?
No
Yes. If yes, estimate the number of hours per week:
per month:
If employee just started working, date first check will be issued:
Number of hours this check covers:
Pay Date Information
Employee is paid (mark one of the following):
What day of the week?
Weekly
Bi-weekly (every two weeks)
What date (e.g. 1st & 5th)?
Monthly
Semi-monthly (twice a month)
Date and day of the week pay period ends. Day:
Date:
Number of days between the pay period ending date and the date paid:
Expected Changes
No
Yes.
If yes, what date?
Do you expect the number of hours to increase or decrease?
New number of hours:
Per:
No
Yes.
Do you expect the rate of pay to increase or decrease?
If yes, what date?
New rate of pay: $
Per:
Employer Information (Please print)
If your employee completed any part of this form, DO NOT SIGN THE FORM. Instead, have your employee
provide a blank replacement form to complete.
Employer Name (First and Last):
Phone Number:
Business Name:
Email:
Address:
Signature:
Under penalty of perjury, I swear or affirm the information I have reported is true and complete.
Employer/Payroll signature:
Date:
Rev. 4/13/2016 | HW0411
Only your employer or payroll clerk may complete and sign this form.
How to use this form
1. Send the completed form to the Department by mail, fax, or email.
2. Contact us if you or your employer have questions about the form.
Contact the Department
Mail: PO Box 83720 Boise, ID 83720-0026
Phone: 1-877-456-1233
Fax: 1-866-434-8278
E-mail: MyBenefits@dhw.idaho.gov
Employee Information (Please print)
Name of Employee:
Social Security Number:
Wage Information
Date Employee Started:
$
Hourly Pay
Average number of hours per week:
Per hour
$
Monthly Salary
Per month Number of days worked per week:
$
Other
Per:
Other Income
Employee receives (mark all that apply):
Type
Tip
Housing/Utilities
Commissions
Bonuses
Overtime
$
$
$
$
$
Amount
How often?
Is overtime anticipated?
No
Yes. If yes, estimate the number of hours per week:
per month:
If employee just started working, date first check will be issued:
Number of hours this check covers:
Pay Date Information
Employee is paid (mark one of the following):
What day of the week?
Weekly
Bi-weekly (every two weeks)
What date (e.g. 1st & 5th)?
Monthly
Semi-monthly (twice a month)
Date and day of the week pay period ends. Day:
Date:
Number of days between the pay period ending date and the date paid:
Expected Changes
No
Yes.
If yes, what date?
Do you expect the number of hours to increase or decrease?
New number of hours:
Per:
No
Yes.
Do you expect the rate of pay to increase or decrease?
If yes, what date?
New rate of pay: $
Per:
Employer Information (Please print)
If your employee completed any part of this form, DO NOT SIGN THE FORM. Instead, have your employee
provide a blank replacement form to complete.
Employer Name (First and Last):
Phone Number:
Business Name:
Email:
Address:
Signature:
Under penalty of perjury, I swear or affirm the information I have reported is true and complete.
Employer/Payroll signature:
Date: