EMPLOYMENT VERIFICATION This section to be completed by

NOTE: Section 1001 of Title 18 of the U.S. Code makes it a criminal offense to make willful false statements or misrepresentations to any Department or Agency of the

United States as to any matter within its jurisdiction.

OHCS Programs Employment Verification (REV 12/2017)

EMPLOYMENT VERIFICATION

This section to be completed by Owner/Agent and Applicant/Tenant

The Owner/Agent must mail, fax or email this form directly to the Applicant’s/Tenant’s employer.

The above named applicant/tenant has applied for or currently resides in rental housing in a community that operates under a state and/or

federal housing program that requires verification of income. The information you provide will remain confidential and will only be used

to determine the applicant’s/tenant’s eligibility to reside at this property.

Employee Name: Job Title

:

Currently Employed

: YES: NO:

Date of Hire Date Employment Ended

Regular WAGES: $ Per Hour Week Bi-Weekly Semi-Monthly Month Year

Average # of Regular Hours/Week: Employee Works Overtime: Yes No

Average # of Overtime Hours/Week: Overtime Rate: $ /hour > Included in YTD? Yes No NA

Avg # of Shift Differential Hours/Week: Shift Differential Rate: $ /hour > Included in YTD? Yes No NA

Commissions/Bonuses: $ /Hour/Week/Month Tips: $ /hour/week/month > Included in YTD? Yes No NA

Gross Year-to-Date (YTD) Earnings: $ Earned From: / / to / /

Any anticipated changes in this employee’s wages within the next 12 months: Yes No

List upcoming change/s: Effective Date:

Employee’s work is Seasonal or Sporadic: Yes No If Yes, indicate lay-off period/s:

Employee participates in a 401K / Retirement Account: Yes No Can employee access funds in the account? Yes No

If the account can be accessed, how much can the employee withdraw without retiring or losing employment? $

I hereby certify, by my signature below that the information I have supplied is true and correct:

Printed Name of Verifier Title of Verifier Phone Number

Signature of Verifier Date Email

Employer – please complete the following: (Mark items N/A if not applicable)

EMPLOYER:

Company Name:

Address:

Email:

Fax#:

PROPERTY:

Property Name:

Address:

Email:

Fax#:

APPLICANT/TENANT (Employee)

Authorization for Release of Information

Printed Name of Applicant/Tenant SSN Last Four Digits Unit # (if assigned)

By my signature, I hereby authorize disclosure of the information requested below in order to determine my eligibility to

rent a unit at the property identified above and as required by the funding program/s associated with it.

Signature of Applicant/Tenant Date