MISSOURI DEPARTMENT OF SOCIAL SERVICES FAMILY SUPPORT DIVISION EMPLOYMENT INFORMATION REQUEST
FROM	OFFICE	CASE DCN
ADDRESS	CASE NAME
CITY	STATE MO	ZIP CODE
TO	NAME	PLEASE NOTE: To comply with Federal regulations, our agency is required to make
ADDRESS (STREET NAME AND NUMBER)	a decision on this application within 28 days. We are unable to make this decision without your help and cooperation.
CITY	STATE	ZIP CODE
RE	EMPLOYEE NAME	SOCIAL SECURITY NUMBER - -
EMPLOYEE ADDRESS
AUTHORIZATION FOR RELEASE OF INFORMATION
NAME	DATE
The above named person is a member of a household who is receiving or has made application for public assistance. To determine eligibility and the amount of assistance, we must have information about this person’s income and expenses. It is important that we have: Dates checks are received and pay period ending dates, Rate of pay and hours worked, Amount of gross earnings, Anticipated changes in rate of pay or hours worked, and Other benefits you provide your employee. We have provided a form on the back of this letter to enter this information. If this form is not easy for you to use, you may use a separate sheet or provide a printout and attach it to this form. If the employee is no longer working for you, please complete the section entitled Terminated Employment and enter earnings information for the dates indicated. If the employee is retired from your company, please complete the section entitled Retirement and enter earnings information for the dates indicated. We appreciate the time you are taking to give us this information and thank you for your cooperation. Enclosed is a self-addressed envelope for your reply. Please fax your response to : - -
FAMILY SUPPORT DIVISION	DATE 12/27/2013	TELEPHONE NUMBER - -
MO 886-0689 (01-2014) (CONTINUE ON REVERSE SIDE)	RETAIN CURRENT FORM IM-12
EMPLOYMENT INFORMATION EMPLOYEE NAME:	CASE DCN:
DATE OF EMPLOYMENT	CURRENT POSITION
IF ON EXTENDED LEAVE, DATE LEAVE STARTED	DATE OF REHIRE OR RETURN FROM EXTENDED LEAVE
TERMINATED EMPLOYMENT: (If person is no longer employed by your company, complete the following)
HOW LONG EMPLOYED?	DATE LAST WORKED	AMOUNT OF LAST CHECK	NO. OF HOURS FOR LAST CHECK	DATE LAST CHECK REC.’D/TO BE REC.’D
REASON FOR TERMINATION
RETIREMENT (If the person is retired from your company, please complete the following):
EFFECTIVE DATE OF RETIREMENT	AMOUNT OF MONTHLY PENSION	DATE FIRST PENSION CHECK RECEIVED
PLEASE GIVE GROSS EARNINGS BY PAY PERIOD FOR:	DATE	THROUGH DATE
If this is a new hire, project hours per pay period and amount of first check
HOW MANY HOURS PER WEEK SCHEDULED TO WORK?	DATE CHECK RECEIVED	PAY PERIOD ENDING DATE	RATE OF PAY	HOURS WORKED	GROSS EARNINGS	TIPS (IF NOT INCLUDED IN GROSS EARNINGS)	FOOD ALLOW. (IF NOT INCLUDED IN GROSS EARNINGS)	SICK OR VAC.PAY
PAY PERIOD:
Monthly
Twice a Month
Every 2 Weeks
Weekly
Other
DO THE WAGES INCLUDE OVERTIME? YES NO IF YES, AMOUNT	DOES JTPA PAY PART OF THE WAGES? YES NO IF YES, AMOUNT
ARE THERE SEASONAL CHANGES THAT AFFECT THE EARNINGS OF THE EMPLOYEE? YES NO IF YES, EXPLAIN:
ARE THE WAGES OR NUMBER OF HOURS WORKED EXPECTED TO CHANGE IN THE NEXT 6 MONTHS? YES NO IF YES, EXPLAIN:
BENEFITS
DOES THIS EMPLOYEE HAVE HEALTH INSURANCE YES NO	Enter Amount for Other Benefits Employee has
OR SICK BENEFIT COVERAGE?
AMOUNT
IF YES, COMPANY NAME:	Company Dividends
Company Shares or Stock
POLICY NO.	Credit Union
Voluntary Deductions
PREMIUM PAID BY: EMPLOYER? EMPLOYEE?	Savings Bonds
Premium AMOUNT PAID BY EMPLOYEE $____________ PER ___________	401K Account
WHO IS COVERED? EMPLOYEE? SPOUSE? FAMILY?	Other
IS THERE A WORKER’S COMPENSATION CLAIM PENDING YES NO OR BEING PAID? IF YES, AMOUNT
SIGNATURE OF PERSON COMPLETING FORM	DATE
PRINT NAME and TITLE	TELEPHONE NUMBER
MO 886-0689 (01-2014)