Form SFN59246 "Esg/Ndhg Verification of Income" - North Dakota

What Is Form SFN59246?

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

Form Details:

  • Released on August 1, 2013;
  • The latest edition provided by the North Dakota Department of Commerce;
  • 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 fillable version of Form SFN59246 by clicking the link below or browse more documents and templates provided by the North Dakota Department of Commerce.

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Download Form SFN59246 "Esg/Ndhg Verification of Income" - North Dakota

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ESG/NDHG VERIFICATION OF INCOME
NORTH DAKOTA DEPARTMENT OF COMMERCE
DIVISION OF COMMUNITY SERVICES
SFN 59246 (8/13)
Applicant Name
Instructions for Employer/Payment Source Representative: This is to certify the income received by the above named
individual for purposes of participating in the ESG program. This information will be used only to determine the eligibility status
and level of benefit of the household. Complete only the selected section below that includes an authorization to release
information.
PLEASE RETURN THIS FORM TO:
Name
Title
Address
City
State
ZIP Code
Email
Phone
Fax
Employment Income
Applicant Release: I hereby authorize the release of the following employment information.
Applicant Signature
Date
EMPLOYER REPRESENTATIVE TO COMPLETE THIS SECTION
Employer
Date Employed
Salary/Wages
Hours Worked
Weekly
Monthly
Yearly
Weekly
Monthly
Additional Compensation Please Specify (if any)
Probability of Continued Employment
Authorized Employer Representative Signature
Date
Phone
Name
Title
Address
City
State
ZIP Code
Payments and/or Benefit Income (complete one form for each distinct source of income for person named above)
Check one:
Social Security/SSI
Pension/Retirement
TANF
Unemployment Compensation
Workers Compensation
Alimony Payments
Foster Care Payments
Child Support Payment
Armed Forces Income
Public Assistance
Other (please specify):
Applicant Release: I hereby authorize the release of the following payment and/or benefit information.
Applicant Signature
Date
PAYMENT SOURCE REPRESENTATIVE TO COMPLETE THIS SECTION
Amount of Payment/Benefit
Payment Frequency
Expected Duration of Payments/Benefits
Authorized Payment Source Representative Signature
Date:
Name
Title
Address
City
State
ZIP Code
ESG/NDHG VERIFICATION OF INCOME
NORTH DAKOTA DEPARTMENT OF COMMERCE
DIVISION OF COMMUNITY SERVICES
SFN 59246 (8/13)
Applicant Name
Instructions for Employer/Payment Source Representative: This is to certify the income received by the above named
individual for purposes of participating in the ESG program. This information will be used only to determine the eligibility status
and level of benefit of the household. Complete only the selected section below that includes an authorization to release
information.
PLEASE RETURN THIS FORM TO:
Name
Title
Address
City
State
ZIP Code
Email
Phone
Fax
Employment Income
Applicant Release: I hereby authorize the release of the following employment information.
Applicant Signature
Date
EMPLOYER REPRESENTATIVE TO COMPLETE THIS SECTION
Employer
Date Employed
Salary/Wages
Hours Worked
Weekly
Monthly
Yearly
Weekly
Monthly
Additional Compensation Please Specify (if any)
Probability of Continued Employment
Authorized Employer Representative Signature
Date
Phone
Name
Title
Address
City
State
ZIP Code
Payments and/or Benefit Income (complete one form for each distinct source of income for person named above)
Check one:
Social Security/SSI
Pension/Retirement
TANF
Unemployment Compensation
Workers Compensation
Alimony Payments
Foster Care Payments
Child Support Payment
Armed Forces Income
Public Assistance
Other (please specify):
Applicant Release: I hereby authorize the release of the following payment and/or benefit information.
Applicant Signature
Date
PAYMENT SOURCE REPRESENTATIVE TO COMPLETE THIS SECTION
Amount of Payment/Benefit
Payment Frequency
Expected Duration of Payments/Benefits
Authorized Payment Source Representative Signature
Date:
Name
Title
Address
City
State
ZIP Code