Wage Verification Form

10 Johnston County HAPP 107 E Johnston St , PO Box 1515 , Smithfield , NC 27577 919 989 - 5070 Fax 919 989 - 5421 wwwjohnstonnccom happ The US Department of Housing and Urban Development HUD requires our agency to verify the income of each family member who has applied for or is receiving assistance We ask for your cooperation in completing the information on this page Thank you in advance for your prompt attention A self - addressed stamped envelope is enclosed for your convenience PART I REQUEST 1 To Name and Address of Employer 2 From Name of Housing Agency This item must be completed before sending to employer JOHNSTON COUNTY HOUSING ASSISTANCE PAYMENTS PROGRAM 3 I certify that this verification has been sent to the employer and has not passed through the hands of the applicant or any other interested party ______________________________________________________ DATE _____________________________________ Signature of HAPP Staff Member PART II RELEASE of INFORMATION I HEREBY AUTHORIZE THE RELEASE OF EMPLOYMENT VERIFICATION 4 Name & Address of Employee 5 Employee’s Social Security No 6 Signature Date v PART III VERIFICATION of EMPLOYMENT EMPLOYMENT DATA PAY DATA 7 Date of Employment 10 A Base Pay Current or Other Income Bas ____________Annual ____________Hourly 8 Present Position ____________Monthly ____________Weekly ____________Other Specify _____________Tips 9 Probability of Continued Employment 10 B Earnings Year to Date as of ____________ Past Year 11 If Overtime or Bonus if Applicable is its Continuance Type Likely Base Pay ________________________ _________________________ Overtime ______Yes ______No Bonus ______Yes ______No Overtime _________________________ ________________________ Commissions ________________________ _________________________ 12 Remarks If paid hourly , please indicate average hours worked each week during current & past year Bonus ________________________ _________________________ a Number of Hours worked per week ________ b Anticipated Increase or Decrease in salary in next 12 months ________ Anticipated overtime hours to be worked in next 12 months ________ 13 Dates of Employment 14 Salary Range at Termination per _____Year _____Month _____Week Base Pay ___________ Overtime ___________ Commissions __________ Bonus __________ 15 Reasons for Leaving 16 Position Held Federal statues provide severe civil and criminal penalties for any person who knowingly makes false or fraudulent statements or representation to a government agency or officer with the intention of influencing any action by such agency or officer 18 Title of Employer 19 Date 17 Signature_______________________________________________ Printed Name & Number______________________________________Page