The Job and Family Services Hamilton Ohio form is a crucial document used for employment verification in Hamilton County. This form facilitates the process of determining eligibility for various assistance programs, including cash, food, and medical support. By providing necessary employment details, applicants help ensure a smooth evaluation of their needs.
The Job and Family Services Hamilton Ohio form is a critical document used to verify employment and determine eligibility for various assistance programs in Hamilton County. This form is specifically designed for individuals applying for assistance through the Hamilton County Department of Job and Family Services. It includes essential sections such as employment verification requests, personal information of the applicant, and details about the employer. Applicants must provide their Social Security number, case number, and consent for the release of employment information. The form also requires the employer to fill out details about the employee's work history, including dates of employment, reasons for separation, and current pay rates. Additionally, it addresses health insurance enrollment for the employee and their dependents, ensuring that all relevant factors are considered when assessing eligibility for cash, food, and medical assistance. By signing the form, applicants acknowledge their responsibility to report accurate information, understanding the potential consequences of providing false details. This comprehensive approach helps streamline the process of determining eligibility while safeguarding the integrity of the assistance programs offered.
Southwest Ohio
County Departments of
Job & Family Services
County Agency: Hamilton County Job & Family Services
Address: 222 E. Central Parkway, Cincinnati, OH 45202 Phone: (513) 946-1000 Fax: (513) 946-1076 Website: www.hcjfs.org
Employment Verification Request
JFS Worker:
Phone:
Date:
Return by:
Employer Name:
Employee Name:
Employer Address:
Social Security Number:
City:
State:
Zip:
Case Number:
By applying for CDJFS programs, the individual has agreed that the CDJFS may contact other persons or organizations to obtain the necessary proof of eligibility and level of assistance. In addition, Ohio Revised Code 5101.37 authorizes the CDJFS to make investigations that are necessary in the performance of their duties.
Authorization for Release of Information
I agree that the employer named below may release my employment information to Hamilton County Job & Family Services & the Cincinnati Metropolitan Housing Authority.
This information will be used to determine eligibility for:
Cash Assistance;
Food Assistance;
Medical Assistance;
Other, specify:
.
I am aware of my responsibilities to report completely and fully all facts which bear upon my eligibility for assistance. I realize if the requested information reveals I have improperly reported my situation, the information may be given to the prosecuting attorney for possible civil action or criminal prosecution.
Signature of Applicant/Recipient:Date:
Employer to Complete
Dates of Employment
Corporate Name:
If employment has ended, also complete this section.
Name of Employment Site:
Last Day Worked:
Date Last Pay Received:
Type of Separation:
First Day Worked:
Laid Off
Illness or Injury
No Call or Show
Other (specify): ____________________
Resignation
Eligible for Post-Employment Benefits (specify):
Date First Pay Received:
Discharged
List interruption or leave period during employment.
Strike Start Date:
Strike End Date:
Effective Lockout Date:
From Date:
To Date:
Rate/Hours/Pay Frequency
Current Hourly Rate:
Day of Week Paid:
Pay Period Frequency:
Overtime is:
Weekly
Twice Monthly
Not expected to be worked in the future
Biweekly
Other (Specify)
__
Worked routinely monthly
Number of set hours to work per Week:
; OR
Number of hours will vary from __________ to __________ per Week
Wages (Last 6 Pays)
Date
Hourly
Gross Pay
Bonus or
Child Support
Period Ending
Hours
WITHOUT Tips, Bonus
Tips
Garnishment
Received
Rate
Commission
Deduction
or Commission
Health Insurance
Is the employee or their dependents enrolled in health insurance?
Begin Date:
End Date:
Policy Number:
Group Number:
No
Yes
Name/Address of Insurance Company:
List Covered Members:
Additional Information Needed For Time Period Below (See Reverse only if Time Period is Noted Below)
Time Period Requested – From Date:
Employer Signature
Employer Representative Signature:
Title:
FAX:
SWOJFS 2775 (REV. 10-12)
Page 1 of 2
(SWOJFS 3)
Employee Social Security Number:
If indicated on the front side, complete the following information for the time period indicated on page 1 of this form. If it is more convenient or you need more space, please substitute copies of the employee’s payroll records.
Date Pay Received
Gross Pay Without Tips, Bonus or Commission
Other Information Requested
Requested Information:
Employer Response to Requested Information:
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