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Y Ark VERIFICATION OF : Employment - Applicant Name of Employer: (Applicant Information) Employed Since Occupation Name of Applicant or Tenant : Pay rate: Date of Next Increase Pay Frequency (Hr, Wk , Mo) : Average Hours per Week at Base Pay Rate: Social Security Number: Hours Weeks or Months worked per year. Return to . Average number of overtime hours expected during the next 12 months Overtime Pay Rate: Per Hour . NSP Program Coordinator Indian River Habitat for Humanity Total Base Pay expected for the next 12 months$ 4568 N . US Highway 1 Vero Beach , FL 32967 Any other compensation not included above (specify for commissions, bonuses, tips, etc.) Pax : 772 - 562 - 8732 FOR $ Per . Vacation Pay (Y or N) If yes , Number of days per year Total Base Pay Earnings for past 12 months $ Your prompt return of the requested information will Total Overtime Earnings for past 12 months $ be appreciated . A self-addressed return envelope IS Probability & Expected Date of Any Pay Increase : enclosed . Does the employee have access to a Retirement Account? ❑ Yes ❑ No If yes, what amount can they get access to? $ * Employers — Please complete this sect RELEASE : I hereby authorize the release of Signature of or the requested information . X Authorized Representative •( Signature of Applicant/Tenant) Date : Agency Name : or ; Title : A copy of the executed " Release of Information Form " is attached which authorizes the release Date : of information requested . Telephone : WARNING : Florida Statute 817 provides that willful false statements or misrepresentation concerning income and assets or liabilities relating to financial condition is a misdemeanor of the first degree and is punishable by fines and imprisonment provided under S 775.082 or 775. 83 .