BFA Form 756 "Employment Verification" - New Hampshire

What Is BFA Form 756?

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

Form Details:

  • Released on October 1, 2019;
  • The latest edition provided by the New Hampshire Department of Health and Human Services - Bureau of Family Assistance;
  • 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 BFA Form 756 by clicking the link below or browse more documents and templates provided by the New Hampshire Department of Health and Human Services - Bureau of Family Assistance.

ADVERTISEMENT
ADVERTISEMENT

Download BFA Form 756 "Employment Verification" - New Hampshire

237 times
Rate (4.4 / 5) 11 votes
NH Department of Health and Human Services (DHHS)
BFA Form 756
Bureau of Family Assistance (BFA)
10/19
Employment Verification
(Completed by Employer Only)
FROM:
Eligibility Worker Name:
Telephone #:
Centralized Scanning Unit (CSU)
P.O. Box 181
Today’s Date:
Concord, NH 03301
Please complete and return by:
FOR CURRENT EMPLOYMENT
Name of Employee:
SSN:
-
-
Date of Hire:
Job Title:
Av. Hrs per Week:
Current Rate of Pay: $
per
st
EIN:
If this is new employment, the date of the 1
paycheck:
Frequency of pay:
Weekly
Bi-weekly
Monthly
Semi-monthly
(circle one)
Please indicate if the employee has any of the following deductions:
Credit Union Account(s)
Share/Profit Sharing
Retirement Fund/IRA
Mandatory Wage Assignment
(i.e., Child Support Assignment)
Medical Insurance:
Savings Bond(s)
Self
Family
Do you anticipate any changes in rate of pay or hours?
Yes (use back of form to explain)
No
FOR TERMINATED EMPLOYMENT
Name of Employee:
SSN:
-
-
Date of Termination or Leave of Absence:
Circle One: Permanent
Temporary
Reason for Termination:
Actual Date Final Paycheck Received:
Gross Amount of Final Paycheck:
Did the employee receive money from any other sources?
Y
N
If yes, please indicate source,
type, & amount
(i.e., severance pay, worker’s comp, etc.):
Did the employee have medical insurance?
Y
N
End Date?
COBRA
Y
N
COMPLETE THIS SECTION FOR BOTH CURRENT AND TERMINATED EMPLOYMENT
Please list the employee’s gross wages for the last 4 weeks, and indicate all bonuses, tips, or commissions
that are not already included in the gross wages. If the employee receives an Earned Income Tax Credit
(EITC), indicate the amount of the credit.
If not already included in Gross Wages…
Actual Date Paid
Gross Wages
EITC
# of Hours
Tips
Bonus
Commission
Additional Information Requested by the Department:
Yes, see back of form for more details
No
Signature & Title of Person Completing this Form
Date
Company
Telephone Number
Company Address
Fax Number
Thank you for your cooperation.
BFA SR 19-29
(3YC)
This institution is an equal opportunity provider.
NH Department of Health and Human Services (DHHS)
BFA Form 756
Bureau of Family Assistance (BFA)
10/19
Employment Verification
(Completed by Employer Only)
FROM:
Eligibility Worker Name:
Telephone #:
Centralized Scanning Unit (CSU)
P.O. Box 181
Today’s Date:
Concord, NH 03301
Please complete and return by:
FOR CURRENT EMPLOYMENT
Name of Employee:
SSN:
-
-
Date of Hire:
Job Title:
Av. Hrs per Week:
Current Rate of Pay: $
per
st
EIN:
If this is new employment, the date of the 1
paycheck:
Frequency of pay:
Weekly
Bi-weekly
Monthly
Semi-monthly
(circle one)
Please indicate if the employee has any of the following deductions:
Credit Union Account(s)
Share/Profit Sharing
Retirement Fund/IRA
Mandatory Wage Assignment
(i.e., Child Support Assignment)
Medical Insurance:
Savings Bond(s)
Self
Family
Do you anticipate any changes in rate of pay or hours?
Yes (use back of form to explain)
No
FOR TERMINATED EMPLOYMENT
Name of Employee:
SSN:
-
-
Date of Termination or Leave of Absence:
Circle One: Permanent
Temporary
Reason for Termination:
Actual Date Final Paycheck Received:
Gross Amount of Final Paycheck:
Did the employee receive money from any other sources?
Y
N
If yes, please indicate source,
type, & amount
(i.e., severance pay, worker’s comp, etc.):
Did the employee have medical insurance?
Y
N
End Date?
COBRA
Y
N
COMPLETE THIS SECTION FOR BOTH CURRENT AND TERMINATED EMPLOYMENT
Please list the employee’s gross wages for the last 4 weeks, and indicate all bonuses, tips, or commissions
that are not already included in the gross wages. If the employee receives an Earned Income Tax Credit
(EITC), indicate the amount of the credit.
If not already included in Gross Wages…
Actual Date Paid
Gross Wages
EITC
# of Hours
Tips
Bonus
Commission
Additional Information Requested by the Department:
Yes, see back of form for more details
No
Signature & Title of Person Completing this Form
Date
Company
Telephone Number
Company Address
Fax Number
Thank you for your cooperation.
BFA SR 19-29
(3YC)
This institution is an equal opportunity provider.