STATE OF NEVADA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
DIVISION OF WELFARE AND SUPPORTIVE SERVICES
STEVE SISOLAK
Governor
RICHARD WHITLEY, MS
Director
STEVE H. FISHER
Administrator
ATTENTION: Payroll Department
TANF MEDICAID SNAP
Date:
Case Name:
Case ID:
AUTHORIZATION: I authorize you to release to
the Division of Welfare and Supportive Services the
requested information.
Client Signature Date
EARNINGS VERIFICATION
Please provide the information for each of the items below and return to the above address. Your cooperation will help
insure integrity and maintain accountability in the administration of public funds in Nevada. The information provided us
will be used only in conjunction with the official duties of this department and will be considered confidential.
If our identifying information (name, Social Security number or address) does not agree with your records, please indicate
the change.
RE:
Name Social Security Number
Employee's Address:
1. Date work Began: Number of Hours employee is scheduled to work per week:
2. Hourly rate of pay
$
Average hours worked per week: Date of first paycheck:
3. How often are paychecks issued: Weekly Bi-weekly Semi-monthly Monthly
When are regularly scheduled paydays?
4. Will “tips” be received? YES NO If YES: Estimated amount:
$
per
5. Is this employment Contractual? YES NO If YES: Contracted wage amount:
$
per
Maximum Earnings provided in contract:
$
Number of months covered by this contract:
6. Are/Were wages funded in whole or in part by Workforce Incentive (formerly JTPA?) Programs? YES NO
If YES, through: Work experience OR On-the-job training
2074 - EG (224.0.0)
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