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VERIFICATION OF : Employment — Co -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 NSP Program Coordinator 12 months Overtime Pay Rate : Per Hour 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. ) FaX � ; �772 - 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) Agency Name : Date : 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 .