Transcription of nycACS R EV 6/02 NYC Administration for …
1 ACD 1069 REV6/02 referral TO EMPLOYER FOR employee income INFORMATIONE mployee s Name:_____ _ _ _ _ _ _ _ _Program Number:Street Address:_____ _ _ _ _ _ _ _ _ _RAAddress:_____ _ _ _ _ _ _ _ _ _ _City, State & Zip Code:_____ _ _ _ _ _ _ _ _ _ _ _ _Social Security No.:Att.:_____ _ _ _ _ _ _ _ _ _ _To be completed by employer s personnel or payroll department:The above named individual is requesting/receiving publicly funded day care make afinancial eligibility determination, it is necessary to verify income for the last three(3) list overtime, if any, in the appropriate NOT include time and leave penalties inthe REGULAR GROSS of Employment:Start Date:_____ /_____ /_____To:_____ /_____ /_____Type of Work:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Work Days Per Week:_____Hours Daily:From:_____ To:_____ Regular Gross:_____ Per:_____ Circle Regular Work Days: of Employer:_____Employer s Address:_____Employer s Federal ID :( )_ _ _ _ _ _ _ _ _ _ _ _ _ _Signature:_____ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _Title:_____Date:_____ /_____ /_____Note.
2 It may be necessary to verify the income information by Administration for Children s Services
