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 Nyc Referral to Employer for Employee Income Information Form Rev 216 2016-2023

Nyc Referral to Employer for Employee Income Information Form Rev 216 2016-2023

Use a 1069 form 2016 template to make your document workflow more streamlined.

Requesting/receiving publicly funded day care services. To make a financial eligibility determination, it is necessary to verify income for the last three(3) months. Please list overtime, if any, in the appropriate column. Do NOT include time and leave penalties in the “REGULAR GROSS” column. Period of Employment: Start Date: _____ /_____ /_____ To: _____ /_____ /_____ Type of Work: ______________________________ No. of Work Days Per Week: ________ Hours Daily: From: ________ To:...
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