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    CFWB015

    Uploaded by

    Yeshaya Dorfman
    This document contains a consent form for an employee to release their employment and income information to the NYC Administration for Children's Services and Department of Education. It includes sections for the employee to provide their signature and date consenting to the release. There are also sections for the employee's supervisor or payroll department to complete to verify the employee's income over the past three months and twelve weeks. The employer must provide information about the employee's salary, wages, work schedule, and gross income received in each of the past twelve weeks. At the bottom, the employer signs and dates to affirm the financial information provided about the employee is true and accurate.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    CFWB015

    Uploaded by

    Yeshaya Dorfman
    386 views2 pages
    This document contains a consent form for an employee to release their employment and income information to the NYC Administration for Children's Services and Department of Education. It includes sections for the employee to provide their signature and date consenting to the release. There are also sections for the employee's supervisor or payroll department to complete to verify the employee's income over the past three months and twelve weeks. The employer must provide information about the employee's salary, wages, work schedule, and gross income received in each of the past twelve weeks. At the bottom, the employer signs and dates to affirm the financial information provided about the employee is true and accurate.

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    © © All Rights Reserved

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    This document contains a consent form for an employee to release their employment and income information to the NYC Administration for Children's Services and Department of Education. It includes sections for the employee to provide their signature and date consenting to the release. There are also sections for the employee's supervisor or payroll department to complete to verify the employee's income over the past three months and twelve weeks. The employer must provide information about the employee's salary, wages, work schedule, and gross income received in each of the past twelve weeks. At the bottom, the employer signs and dates to affirm the financial information provided about the employee is true and accurate.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    386 views2 pages

    CFWB015

    Uploaded by

    Yeshaya Dorfman
    This document contains a consent form for an employee to release their employment and income information to the NYC Administration for Children's Services and Department of Education. It includes sections for the employee to provide their signature and date consenting to the release. There are also sections for the employee's supervisor or payroll department to complete to verify the employee's income over the past three months and twelve weeks. The employer must provide information about the employee's salary, wages, work schedule, and gross income received in each of the past twelve weeks. At the bottom, the employer signs and dates to affirm the financial information provided about the employee is true and accurate.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    CFWB-015

    REV. 12/22

    Referral to Employer for Employee Income Information


    To be completed by Employee
    CONSENT TO RELEASE INFORMATION

    I (employee’s name) , give permission to my current/former



    employer, ,
    (Print the company’s /organization’s /employer’s /owner’s name)
    to release my employment/income information to the NYC Administration for Children’s Services and the D.O.E.

    Employee’s Signature: Date Signed:

    To be completed by Employee’s Supervisor, Personnel or Payroll Department

    Note: The Administration for Children’s Services and the D.O.E. may contact you by telephone to verify employment/
    income information.

    The individual named above is requesting/receiving publicly funded child care services.
    To make a financial eligibility determination, it is necessary to verify income for the last three (3) months.

    Period of Employment:
    Start Date: End Date: Return to Work Date:
    (leave blank if still employed) (if on leave)

    Type of Work:

    Regular Employment Schedule: Hours


    Sunday Monday Tuesday Wednesday
    from to from to from to from to

    Thursday Friday Saturday


    from to from to from to

    Salary/Wages: $

    Income is paid  weekly  bi-weekly  semi-monthly  monthly


    Hourly Wage: $

    Only complete this question if you work in New Jersey. Is your employer a small business?  Yes  No
    Note: A small employer did not employ 10 or more over the course of the year. The size is based on the highest
    total number of employees at any given time during the current or prior calendar year and amongst all sites.

    1 of 2
    CFWB-015
    REV. 12/22

    Gross Payroll Information for the Past Twelve (12) Weeks


    Please list overtime, if any, in the appropriate column. Only complete the applicable section(s) below.
    Service employees must receive a combination of tips and wages as set forth by the New York State
    minimum hourly wage law. Note that weeks that were not worked must still be included
    (enter "0" for Hours Worked and Gross Income).

    Period Ending Hours Salary/ Other Earnings Total


    Overtime Tips
    mm/dd/yyyy Worked Wage Amount Type (Gross Income)

    10

    11

    12

    Total Gross Income

    Business/Employer’s Name (please print):


    Business Street Address:
    Telephone #: Ext.: Federal Tax ID #:

    I swear and/or affirm that all the financial information I have given related to the
    employee named above is true and accurate.

    Employer’s Signature:

    Title: Date Signed:

    2 of 2

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