Employment Verification for Child Care Scholarship Eligibility |

School: Southern New Hampshire University - Course: ACC TAXATION - Subject: Accounting

Last Day of Employment Verification Parents/Guardians:In order to determine your eligibility for child care scholarship,you must submit documentation of the last day of employment with your previous employer. Employer:We must verify the last day the client listed below worked for you. This must be filled out by the employer. No white out may be used and any changes must be initialed and dated by employer . Please understand that the ELC may contact and/or visit your employer to verify the information presented on this form. This form should only be utilized for verification of last day of employment. Additional documentation may be requested. SECTION I - GENERAL INFORMATION: (To be completed by employer) 1.Employee Name____________________________________SS#______________________________ 2.Employee Address____________________________________________________________________ 11.If no longer employed: Date Employment Ended:_____________________Date/Amount last check received:__________/$_____________ SECTION II - EMPLOYER INFORMATION: (To be completed by employer) 1.Employer Representative:___________________________________________ 2.Title:_____________________ 3.Business Name:___________________________________________ 4.Phone #:_________________ 5.Business Address:____________________________________________________________________ SECTION III - EMPLOYER VERIFICATION: The information provided on this form is true and complete . If I knowingly omit or give false information, I may be liable for prosecution under the law.Self-Employment must be documented by submitting Income Tax Return and/or business records and receipts for expenses. _______________________________________________________________ Employer Representative SignatureDate SR- 60F-96 Rev 12162019Catherine Bonnie222-78-0436 127800 118th St., Largo, FL 33778 11/13/202011/27/202,964.19 Judi Brown Payroll Administrator Achieva Credit Union 727-431-7350 PO Box 1500, Dunedin, FL 34697 12/1/2021

Family Services 2536 Countryside Blvd, Suite 500 Clearwater, FL 33763 (727) 400-4411www.elcpinellas.net Fax: (727) 400-4486 Employment Verification Parents/Guardians:In order to determine your eligibility for child care scholarship,you must submit copies of the most current consecutive four weeks pay stubs or have your employer completethis form.Self-Employment mustbedocumented bysubmitting Income Tax Return and/or business records and receipts for expenses. Employer:We must verify both employment and income on the below listed client. This must be filled out by the employer. No white out may be used and any changes must be initialed and dated by employer.Please understand that the ELC will contact and/or visit your employer to verify the information presented on this form. This form should only be utilized for new employment or in rare circumstances where four weeks of most current/consecutive pay stubs cannot be obtained. Additional documentation may be requested. SECTION I - GENERAL INFORMATION: (To becompletedby employer only) 1. Employee Name ____________________________________________________________________SS#______________________________________ 2. Employee Address ________________________________________________City:___________________________State:_________________Zip:___________________ 3. Type of work performed by employee: ________________________________________Employment began:_________/_________/__________ 4. Hourly wage received by employee: $___________________5. Number of hours worked per week:____________________(DO NOT PUT VARIES) 6. Number of days per week: _________________________ Employee paid: $___________________WeeklyBi-weeklySemi-monthlyMonthlyOther_____________________ Does employee receive and/or have access to paystubs?YesNo Does employee receive a 1099?YesNo 7. Work schedule: From: _____________A.M.P.M.To: ______________A.M.P.M. 8.Does employee receive commission/tips?YesNo(If yes, show commission/tips in section III). 9. Estimated income from commission/bonuses over the next 12 months is: $_______________________ 10. Is employment year round?YesNo IfNO, specify number of consecutive months:1211½1110 ½109½9Other____________________ 11.If no longer employed, Date Employment Ended: ________________________Date/Amount last check received: _______________/$_______________ SECTION II - EMPLOYER INFORMATION: (To be completedby employer) 1.Employer Representative: ______________________________________________Title: ___________________________________ 2.Business Name: __________________________________________________Phone #: (_____)___________________ 3.Business Address: ____________________________________________City:_____________________________State:____________Zip:_________________ SECTION III - RECORDOF PAY RECEIVED: (To becompletedby employer) 1.In the space below, list the most current and consecutiveFOURweeks of checks or cash received by the employee along with the date pay was issued, gross amount paid, hours worked, tips (if applicable) and net amount paid.