Section 1 General Information
First Name:
Date of Birth (DOB):
Social Security Number (SSN) (optional):
Section 2
New/Current Employment
Job Title:
Hourly Wage:
Paid per:
Week
Bi-Weekly
Period Ending
Gross Pay
Number of Hours Worked Per Week:
Section 3 Job Termination
Last Day of Work:
Is Employee on Leave Without Pay?
Yes
Section 4
Employer Information
Maryland State Department of Education/Office of Child Care
Child Care Scholarship Program
EMPLOYMENT VERIFICATION STATEMENT
Last Name:
Contact Phone Number:
Job Start Date: MM/DD/YYYY
Tips:
Commission:
Semi-Monthly
Monthly
Return to:
https://family.childcareportals.org/
Work Schedule: (If schedule varies, indicate number of days worked per week.)
Date Received
Hours Worked
Does Employee Work:
Evenings/Nights (7pm – 6am)
Weekends
Date Final Pay Received:
Gross Amount of Final Check:
No
If Yes, Expected Date of Return:
Consent for Release of Information
I understand that this information will be verified and used by the Child Care Scholarship Program to determine my eligibility for child care
scholarships.
Signature:
Company Name:
Address:
Name of Person Completing Form:
Signature:
Title:
Date: MM/DD/YYYY
Section 5
Signature
Date:
Phone Number:
Phone Number:
MSDE-CCSCENTRAL DOC.221.23 Revised 05/01/2021
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