Form DWS-ESD630T "Monthly Employment and Income Statement Temporary Employment Agency" - Utah

What Is Form DWS-ESD630T?

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

Form Details:

  • Released on January 1, 2020;
  • The latest edition provided by the Utah Department of Workforce 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 DWS-ESD630T by clicking the link below or browse more documents and templates provided by the Utah Department of Workforce Services.

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Download Form DWS-ESD630T "Monthly Employment and Income Statement Temporary Employment Agency" - Utah

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DWS-ESD 630T
State of Utah
Rev. 01/2020
Department of Workforce Services
MONTHLY EMPLOYMENT AND INCOME STATEMENT
TEMPORARY EMPLOYMENT AGENCY
Case name:
Case number:
D32319901240101
Employed person:
Date:
Complete the following form and provide any pay stubs or wage printout for income
received in the last 90 days. Please use a black pen to complete form.
Temporary Employment Agency Information:
Company name:
Corporate name (if different):
Payroll company (if different):
Company address:
Name of supervisor or HR contact:
Phone number:
Employment Information:
1. Date employee registered with agency:
2. Date employee began new assignment:
3. What is the status of the employee’s new assignment? (check one)
Full-time
Part-time
Other (explain):
How long will the assignment last?
4. Hourly wage: $
/hr. or Salary: $
/Monthly
/Yearly
5. Hours employee will be working:
/wk.
Check scheduled work days:
Mon
Tues
Wed
Thurs
Fri
Sat
Sun
Enter work schedule
From:
a.m. / p.m. To:
a.m. / p.m.
(example: 9 a.m. to 6 p.m.)
6. How often paid? (check one):
Daily
Weekly
Other (explain):
7. Day of week check is available:
Date first check received:
If current assignment has ended:
1. Date last worked:
Date last paid:
2. Gross amount of last paycheck (before taxes): $
3. Total gross pay in the month employee received their last check (before taxes): $
4. Are additional assignments available?
Yes
No
5. When will additional assignments be available for the employee?
6. Has the employee turned down any assignments? (explain if yes):
Employer Signature*
Date
*Additional verification will be required if employer does not sign form.
Customer Signature
Date
Return form to employee or to Department of Workforce Services:
Mail - Department of Workforce Services, Imaging Operations, P.O. Box 143245, Salt Lake City, UT 84114-3245
Fax - Salt Lake City Area: 801-526-9500 or Toll free: 1-877-313-4717
Equal Opportunity Employer/Program
Auxiliary aids and services are available upon request to individuals with disabilities by calling 801-526-9240. Individuals
who are deaf, hard of hearing, or have speech impairments may call Relay Utah by dialing 711. Spanish Relay Utah: 1-888-346-3162.
DWS-ESD 630T
State of Utah
Rev. 01/2020
Department of Workforce Services
MONTHLY EMPLOYMENT AND INCOME STATEMENT
TEMPORARY EMPLOYMENT AGENCY
Case name:
Case number:
D32319901240101
Employed person:
Date:
Complete the following form and provide any pay stubs or wage printout for income
received in the last 90 days. Please use a black pen to complete form.
Temporary Employment Agency Information:
Company name:
Corporate name (if different):
Payroll company (if different):
Company address:
Name of supervisor or HR contact:
Phone number:
Employment Information:
1. Date employee registered with agency:
2. Date employee began new assignment:
3. What is the status of the employee’s new assignment? (check one)
Full-time
Part-time
Other (explain):
How long will the assignment last?
4. Hourly wage: $
/hr. or Salary: $
/Monthly
/Yearly
5. Hours employee will be working:
/wk.
Check scheduled work days:
Mon
Tues
Wed
Thurs
Fri
Sat
Sun
Enter work schedule
From:
a.m. / p.m. To:
a.m. / p.m.
(example: 9 a.m. to 6 p.m.)
6. How often paid? (check one):
Daily
Weekly
Other (explain):
7. Day of week check is available:
Date first check received:
If current assignment has ended:
1. Date last worked:
Date last paid:
2. Gross amount of last paycheck (before taxes): $
3. Total gross pay in the month employee received their last check (before taxes): $
4. Are additional assignments available?
Yes
No
5. When will additional assignments be available for the employee?
6. Has the employee turned down any assignments? (explain if yes):
Employer Signature*
Date
*Additional verification will be required if employer does not sign form.
Customer Signature
Date
Return form to employee or to Department of Workforce Services:
Mail - Department of Workforce Services, Imaging Operations, P.O. Box 143245, Salt Lake City, UT 84114-3245
Fax - Salt Lake City Area: 801-526-9500 or Toll free: 1-877-313-4717
Equal Opportunity Employer/Program
Auxiliary aids and services are available upon request to individuals with disabilities by calling 801-526-9240. Individuals
who are deaf, hard of hearing, or have speech impairments may call Relay Utah by dialing 711. Spanish Relay Utah: 1-888-346-3162.