WAGE VERIFICATION FORM

Requesting Party

Name __________________________

Phone __________________________

E-Mail __________________________

Fax __________________________

Employee Consent

I, __________________________, authorize and hold harmless of any legal and financial  liability my employer to release to the requesting party listed above. I understand that this  information may be verified by phone, fax, or e-mail.

Signature ________________________ Date __________ Print ________________________ TO BE COMPLETED BY THE EMPLOYER ONLY 

Employee Job Title: ________________________ Start Date: __________ On Leave? ☐ Yes ☐ No

If Yes, Type of Leave: __________________________________

If Yes, Return Date: __________

Monthly Average  

Hourly Pay: $__________ Commission: __________ Tips: __________  Pay Period: ☐ Weekly ☐ Bi-Weekly ☐ Monthly Paid in Cash? ☐ Yes ☐ No

Do Hours Vary? ☐ Yes ☐ No

If Yes, Explain: _______________________________________

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EMPLOYER CERTIFICATION

Employer / Company Name: ________________________  

Address: ________________________ City: ________________________ State: __________ Phone: ________________________ E-Mail: ________________________ I certify that the information listed above is true and accurate to the best of my knowledge. Signature ________________________ Date __________ Print ________________________ Title: ________________________

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