"Verification of Employment/Loss of Income Form" - Sarasota County, Florida

What Is a Verification of Employment/Loss of Income Form?

A Verification of Employment/Loss of Income Form is a legal document needed to confirm an applicant's eligibility for several assistance programs in Sarasota County and apply and manage for benefits. Whether you need Food Assistance to buy healthy food, Temporary Cash Assistance to help you become self-supporting and pay for your expenses and bills, or Medicaid to obtain coverage and save significantly on your bills, this is the document for you. Various forms can be completed in the eligibility determination process - for instance, Verification of Dependent Care Expenses, School Verification, and Verification of Shelter Expenses. A Verification of Employment form must be filled out and signed by your employer who receives the form with the name of the employee and the date by which the document must be filed.

This form was released by the Florida Department of Children and Families. The latest version of the form was issued in May 2010 with all previous editions obsolete. You can download a fillable Sarasota County Verification of Employment/Loss of Income Form through the link below.

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Download "Verification of Employment/Loss of Income Form" - Sarasota County, Florida

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VERIFICATION OF EMPLOYMENT/LOSS OF INCOME
 
________________________________
Date: ____________________
 
________________________________
In order to determine the eligibility of _____________________________________________ for public assistance, 
please assist us by answering the questions below and returning this form to us as soon as possible. 
Office Address/Fax  Number: 
___________________________________________ 
Sarasota County Health Department 
Client’s name 
2200 Ringling Blvd 
___________________________________________ 
Sarasota, FL 34237 
Client’s date of birth 
Fax: 941‐861‐2796 
 
                Please complete each section which is applicable or has been marked on Page 1 AND Page 2 of this form. 
☐ Section I – GENERAL INFORMATION 
 
1. Name of Employee:________________________________________ *Social Security Number:____________________ 
 
    Address:_________________________________________________________________________________________ 
2. Job Title:_________________________________________ Type of Work Performed:___________________________ 
 
3. Number of Hours Worked Per Week:________________ Number of Days Worked Per Week:_______________ 
4. A. How often is/was the employee paid?   ☐ Day      ☐Week     ☐ Bi‐Weekly     ☐ Monthly 
 
    B. Rate of pay: $___________ per ___________ . Other ______________________________Hr./Day/Wk./etc. (Explain) 
 
5. Date current employment began:___________________ Date previously employed:____________________________ 
6. Does/did employee receive tips?    ☐Yes    ☐ No     (If yes, please show tips in Section III.) 
 
7. Is/was employment seasonal? Yes No If yes, season begins:_______________   ends:___________________________ 
 
8. Is/was the employee covered by health insurance?     ☐Yes    ☐ No 
    If yes, name of insurance company:____________________________________________________________________ 
 
9. Number of dependents covered:________________ 
10. Does/did the employee participate in any type of payroll savings plan or profit sharing?   ☐ Yes    ☐No 
 
      If yes, what is the balance? $____________________ 
 
11. Does the person perform their job duties:   ☐in their home    ☐in your home    ☐N/A 
☐ Section II –VERIFICATION OF LOSS OF INCOME AND/OR UNPAID LEAVE 
 
1. Date employment ended/Last day before unpaid leave:___________________________________ 
2. Reason for termination/unpaid leave:____________________________________________________________________ 
 
3. Is the loss of income Permanent or Temporary (ex. maternity leave)?  If temporary, when do you expect the  employee 
 
    to return to work? __________________________________________________________________________________ 
4. Date employee received final check:_______________________ Gross amount: $____________________ 
 
    (Please list last 4 weeks in Section III.) 
5. Will employee receive any vacation pay, retirement refund, or other?   ☐ Yes    ☐ No 
 
    If yes, what type? _____________________ Date received:___________________ Amount: $________________ 
 
6. Is employee eligible for any type of benefits from your company, such as extended insurance coverage, workers’ 
compensation, or other? Yes No If yes: 
 
A. Name of insurance company:_______________________________________________________________________ 
B. Reason for benefits:______________________________________________________________________________ 
 
 
VERIFICATION OF EMPLOYMENT/LOSS OF INCOME
 
________________________________
Date: ____________________
 
________________________________
In order to determine the eligibility of _____________________________________________ for public assistance, 
please assist us by answering the questions below and returning this form to us as soon as possible. 
Office Address/Fax  Number: 
___________________________________________ 
Sarasota County Health Department 
Client’s name 
2200 Ringling Blvd 
___________________________________________ 
Sarasota, FL 34237 
Client’s date of birth 
Fax: 941‐861‐2796 
 
                Please complete each section which is applicable or has been marked on Page 1 AND Page 2 of this form. 
☐ Section I – GENERAL INFORMATION 
 
1. Name of Employee:________________________________________ *Social Security Number:____________________ 
 
    Address:_________________________________________________________________________________________ 
2. Job Title:_________________________________________ Type of Work Performed:___________________________ 
 
3. Number of Hours Worked Per Week:________________ Number of Days Worked Per Week:_______________ 
4. A. How often is/was the employee paid?   ☐ Day      ☐Week     ☐ Bi‐Weekly     ☐ Monthly 
 
    B. Rate of pay: $___________ per ___________ . Other ______________________________Hr./Day/Wk./etc. (Explain) 
 
5. Date current employment began:___________________ Date previously employed:____________________________ 
6. Does/did employee receive tips?    ☐Yes    ☐ No     (If yes, please show tips in Section III.) 
 
7. Is/was employment seasonal? Yes No If yes, season begins:_______________   ends:___________________________ 
 
8. Is/was the employee covered by health insurance?     ☐Yes    ☐ No 
    If yes, name of insurance company:____________________________________________________________________ 
 
9. Number of dependents covered:________________ 
10. Does/did the employee participate in any type of payroll savings plan or profit sharing?   ☐ Yes    ☐No 
 
      If yes, what is the balance? $____________________ 
 
11. Does the person perform their job duties:   ☐in their home    ☐in your home    ☐N/A 
☐ Section II –VERIFICATION OF LOSS OF INCOME AND/OR UNPAID LEAVE 
 
1. Date employment ended/Last day before unpaid leave:___________________________________ 
2. Reason for termination/unpaid leave:____________________________________________________________________ 
 
3. Is the loss of income Permanent or Temporary (ex. maternity leave)?  If temporary, when do you expect the  employee 
 
    to return to work? __________________________________________________________________________________ 
4. Date employee received final check:_______________________ Gross amount: $____________________ 
 
    (Please list last 4 weeks in Section III.) 
5. Will employee receive any vacation pay, retirement refund, or other?   ☐ Yes    ☐ No 
 
    If yes, what type? _____________________ Date received:___________________ Amount: $________________ 
 
6. Is employee eligible for any type of benefits from your company, such as extended insurance coverage, workers’ 
compensation, or other? Yes No If yes: 
 
A. Name of insurance company:_______________________________________________________________________ 
B. Reason for benefits:______________________________________________________________________________ 
 
 
Client’s Name: _________________________________                      Client’s Date of birth: _________________________ 
 
☐ Section III – RECORD OF PAY RECEIVED IN THE LAST FOUR WEEKS 
List the gross amounts and dates of checks or cash, which were paid for the last four weeks in the space below.
 
 
No. of 
 
 
Regular 
No. of 
Pay Period 
Date Pay 
Rate of Pay 
Rate of Pay for 
Tips $$ 
GROSS 
Hours 
Overtime 
Ending 
Received 
Overtime 
Earnings 
Worked 
Hours 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If the hours or rate of pay has varied in the above period, please state why: 
 
 
 
 
 
Does this client have direct deposit?    ☐ Yes     ☐No 
 
 
 
 
 
☐ Section IV – EMPLOYER INFORMATION 
 
What I have written on this form is true to the best of my knowledge. I know that if I give false
 
information on purpose, I may be subject to prosecution for fraud.
 
 
 
 
_______________________________________________________
____________________________________
 
Signature of Employer
Employer’s Title
 
_______________________________________________________
____________________________________
 
Printed Name of Employer
Telephone Number
 
 
_______________________________________________________
____________________________________
 
Name of Business
Date Completed
 
 
____________________________________________________________ 
 
Address 
 
 
 
*We are requesting you provide the social security number (SSN), but you are not required to provide us the SSN under the law.  However, if 
you give us the SSN we can determine eligibility for assistance or services faster and more accurately.  Social security numbers are used by the 
agency for  income and eligibility verification and other purposes related to administration of our programs
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How to Fill Out a Verification of Employment/Loss of Income Form

The Loss of Income Form instructions are as follows:

  1. Provide the general information - name, social security number, and address of the employee. Indicate the job title, type of work that is performed and where the job duties are performed. Record how many hours and days the applicant works per week and how often is the employee paid. State the date the current employment began or the date of previous employment. If the employee receives tips or the employment is seasonal, provide these details in the form. Write down the health insurance information if applicable. If the employee participates in the payroll savings plan or profit-sharing, record the balance;
  2. If the employment ended and entailed a loss of income, state the date it ended. Provide the reason for termination and indicate if the loss of income is permanent or temporary. Write down the date the employee received the final check and its gross amount. If the employee will receive any vacation pay, retirement refund, or any benefits from the company, record their type and amount;
  3. List the pay periods, dates of checks and cash, gross earnings, and rates of pay applied in the last four weeks. If the rate of pay or hours varied in this period indicate why;
  4. Confirm the statements in the form are true to the best of your knowledge and provide the employer information - the name of the business, employer's title, telephone number, and address. Sign and date the form.
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