VERIFICATION OF EMPLOYMENT HOURS

VERIFICATION OF EMPLOYMENT HOURS
Participant Name: __________________________________________________ Client/Recipient ID:_______________________
(Print First & Last Name)
Section 1 - Employment Information
(To Be Completed By Employer or By MW! Staff if Done Via Phone Contact)
Employer Name:
Employer Address, Phone, & Fax:
Date Employment Began: ___________________
Average Actual Weekly Hours Worked: _______________________
Wage: __________________________________
Notes:
How Often Paid?
Weekly
Twice Monthly
Job Title: _______________________________
Every 2 Weeks
Monthly
Section 2 – To Be Completed by Employer
Person Completing Form: __________________________________________________________ Title: ________________________
(Print First & Last Name)
Signature:______________________________________________________________________ Date: __________________________
Section 3- To Be Completed by MW! Staff if Employment is Verified Via Phone
_________________________________________________________________________
(Name of Employer's Staff Verifying Employment Hours)
__________________________________________________________________________________________
(Name of MW! Staff)
_________________________________________________________________________
(Title of MW! Staff)
_____________________________
(Date of Call)
WR-202 Online Version (Revised: 10/01/14)
Equal Opportunity Employer/Service Provider. Michigan Relay Center (800) 649-3777. Auxiliary Aids and Services Available to Individuals with Disabilities