Wage Verification Form

This type of form is used to give third parties express instructions to an employer or the human resources to release personal salary scheme to a third party. In most instances it is used internally in an organization to may be lodge claims e.g. of overtime hours worked etc.

Sample Wage Verification Form

Wage Verification Form

I hereby authorize my employer to release the following information to the Department of Human Services.

________________   _______________  _____________

Client                           Signature                  Date

The employer fills in the following:

Employer’s Name: _____________________________________________________

Address: ________________________________________________________________

City: _________________________ State: __________________ Zip: ______________

Telephone Number: _______________________________________

Employee’s Name: ________________________________________

Social Security Number: ____________________________________

Start Date: ____________________ Estimated Completion Date: ___________________

Gross Salary: _________________________ Hourly Rate: ________________________

Pay Period: Weekly ______ Biweekly ______ Twice Per Month ______ Monthly ______

Hours clocked    Monday Tuesday Wednesday Thursday Friday Saturday Sunday

From:

To:

If irregular hours are worked, please give average hours worked per week ____________.

If irregular hours are worked please mark the shifts that they may work:

Days: _________ Evenings: ___________ Overnight: ___________ Weekends: _________

Comments: ____________________________________________________________________

______________________________________________________________________________

Employer Signature: __________________________________

Title: ________________________________ Date: ________________

Category: Verification Forms