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