Child Support Employment Verification Response Form Template

Employer Name: [Company Name]
Employer Address: [Address]
City, State, ZIP Code: [City, State, ZIP Code]
Phone Number: [Phone Number]
Email Address: [Email Address]

Date: [Date]

To: [Child Support Agency / Court / Attorney / Other Requesting Party]
Address: [Address]
Case Number: [Case Number, if applicable]

1. Employee Information

Employee Full Name: [Full Name]
Employee ID Number: [Number, if applicable]
Last Four Digits of SSN: [XXXX, if applicable]
Job Title: [Job Title]
Department: [Department, if applicable]

2. Employment Status

The above-named individual is currently:

☐ employed
☐ not employed
☐ on leave
☐ terminated
☐ laid off
☐ other: [Describe]

Date Employment Began: [Start Date]
If no longer employed, Last Date Worked: [Date]

3. Work Schedule

Current Work Status:

☐ full-time
☐ part-time
☐ temporary
☐ seasonal
☐ contract or other: [Describe]

Average Hours Per Week: [Number]
Typical Work Days or Shift: [Days / Hours]

4. Compensation Information

Current Rate of Pay: [$Amount]
Pay Type:

☐ hourly
☐ salary
☐ commission
☐ other: [Describe]

Pay Frequency:

☐ weekly
☐ biweekly
☐ semimonthly
☐ monthly
☐ other: [Describe]

Average Gross Pay Per Pay Period: [$Amount]
Average Net Pay Per Pay Period: [$Amount, if provided]

5. Additional Earnings

The employee also receives, if applicable:

☐ bonuses
☐ overtime
☐ tips
☐ commissions
☐ reimbursement or allowance
☐ other: [Describe]

Additional details, if any:

[Insert details]

6. Income Withholding Information

Is income withholding currently in place?

☐ yes
☐ no
☐ unknown

If yes, withholding details are as follows:

Amount Withheld: [$Amount]
Withholding Start Date: [Date]
Agency or Payee Name: [Name]

7. Employment Availability Notes

Additional information about expected continued employment, temporary status, leave, or known changes in pay or schedule:

[Insert notes]

8. Employer Certification

I certify that the information provided in this response is true and correct to the best of my knowledge and based on available employer records.

9. Authorized Signature

Authorized Representative Signature: __________________________
Name: [Full Name]
Title: [Job Title]
Company Name: [Company Name]
Date: [Date]

10. Contact for Follow-Up

If additional information is needed, please contact:

[Full Name]
[Title]
[Phone Number]
[Email Address]