Home Stride Loan Program

Verification of Employment 8-12

VERIFICATION OF EMPLOYMENT AND INCOME

Home Help Plus Loan

PART 1: To Be Signed by Employee:

This will authorize (Name of Employer)

Employer Address

Employer Phone # Employer FAX #

to release the information requested below regarding my employment/compensation/termination.

Street Address of Employee Full Name of Employee (Please Print or Type)

City State Zip Signature

Home Phone Cell Social Security Number Date

PART 2: To Be Completed and Submitted by Human Resources/Personnel Office:

Your employee named above, is applying for a loan to purchase a home. Information requested on this form is necessary to determine eligibility for one of Prince William County’s Homeownership Loan Programs and will be held in strict confidence as is required under the provisions of the Virginia Privacy Protection Act, and will be used only to determine the eligibility of the employee for the loan program. Thank you for your cooperation in completing those applicable portions of this inquiry.

Please Submit to: Office of Housing & Community Development Prince William County

Dr. A.J. Ferlazzo Building - 15941 Donald Curtis Drive # 112, Woodbridge, VA 22192

Attention: Joan S. Duckett FAX (703) 492-0499 Telephone: (703) 492-2301

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1. The applicant is/was employed with

2. Address of employee’s actual work site

3. Date of Hire: ______or Date of Termination:

4. Position Title: ______Current Grade Step

5. Full-time ( ) Part-time ( )

6. Current Gross Yearly Pay: $______Additional Bonus/Overtime per year: $

7. Hours per Week Hourly Rate $ Hourly Overtime Rate $

8. Projected date of next cost of living increase Gross Annual Amount $

9. Projected date of next merit increase and Gross Annual Amount: $

10. Last pay increase received:

Year to Date: 2012 Past Year: 2011

Base Pay $ $

Overtime $ $

Commissions $ $

Total $ $

I certify that the above information is true and correct to the best of my knowledge.

Name of Employer Print Name and Title of Person Completing this Form

Address Signature Date

City State Zip Phone