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OCHA - Employer Verification Form

  1. OCHA Employment Verification Form

    We are required by HUD Regulations to verify the income of all applicants and tenants in our housing programs. We ask your cooperation in supplying the information requested below. This information will be held in confidence for use only in determining family eligibility and rent.

  2. Enter Name of Employee

  3. Enter last four (4) digits of SS number

  4. Enter Start Date of Employment

  5. Enter End Date of Employment

  6. Enter job title of employee

  7. Enter salary or base pay rate

  8. Enter average hours worked - Hours expected

  9. Enter the Overtime Pay Rate

  10. Enter average overtime hours worked - Hours expected

  11. Enter Gross total amount earned year to date

  12. Enter the last pay period end date

  13. Enter name of employer

  14. Enter Supervisor Name and Title

  15. Enter Address of employment

  16. Email address of supervisor/manager

  17. Notice of Verification

    Please be advise employers may be contacted to verify persons completing this form.

  18. Leave This Blank:

  19. This field is not part of the form submission.