Case Name [Case Number Specialist Eric Wits “evoes9e9 {A Gonktn/conkina WAGE VERIFICATION (To be completed by employer) EMPLOYER—Please provide the information requested in sections 1-3. Please return in the enclosed envelope to the specialist and addre shown on page 1 by: 03/19/2021 In accordance with MCL 400.60, 400.8 and 400.83, employers are required to provide the Michigan Department of Human Services with copies of certain papers, records, and documents relevant to an inquiry or investigation conducted by the Department. SECTION 1 - EMPLOYMENT INFORMATION Employment Status ‘Occupation Employed [5] Previously empioyed Date Employment Began (5) Never employed eereeeeeea Temporarily off (explain) Date of Last Paycheck | Type of Employment Q lac off Permanent Quit Temporar OQ Fite Date Employment ended or Is Other (explain) Expected to End | ‘Numbers of Hours Expected to Work |___perweek ee per pay period Rate of Pay | Day of s Crows | Week Piece $ Hour | Paid Salary Shift__| — How Often Paid ‘Are tips/bonus/commission received? C Weexy (ves LINo [1] Twice monthiy ‘Are they included in gross? Every 2 weeks Ye No. 5) Monthiy ‘Average Amount er week C1 other $ er pay period DHS-4638 (Rev. 6-19) Bridges Pago 2013Case Number ‘Specialist a i 121083888 A. conatn conta ‘Section 2~ INCOME INFORMATION Please complete the following information about each pay received during tre period specified below. (Use computer piintout or additional paper to add comments, it necessary.) From: 071012020 Present r pn Taunt of Tip Amount of Tip Soruser Date | Gross | BOWE | Hows Date | Gross | Commission | Hours Recalved| Income | CO™™MIS8ON'] Worked | Received | Income | 'WNot | Worked et Include Included in i Gross SECTION 3 - SIGNATURE/BUSINESS INFORMATION a Business Name Days and Hours of Operations ] Busines Adress Name of Person Completing Form Business Tolophone Number Employer Federal ID (Pease Print) Fen) Slonalue of Parson Completing Form | Tile of Person Completing Ferm |Dato Sgned I ‘statement in order to obtain, or help another obtain, assistance for jubject to legal penalties. if the amount of assistance involved Is more than $500, the violator is quit of a felony. ifthe amount is $500 or less, the violation is a misdemeanor. | ‘The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any Individual or group because of race, religion, age, national origin, color, height, weight, marital status, ‘genetic information, sex, sexual orientation, gender identity or expression, political Beliofs or disabill AUTHORITY: MCL 400.8, MCL 400.83, MCL 400.60 ‘COMPLETION: Required RESPONSE: None PENALTY: Failure to complete this form could result in issuance of a subpoena. [This institution is an equal opportunity provider. (DHS-4698 (Rev. 5-19) Bridges Page 3 of .0082087001709090900