Income Verification Release

Mendocino County Office of Education – State Preschool Consortium

 

INCOME VERIFICATION RELEASE

 

    Child’s Name:__________________________________________________________________


         EMPLOYERS MAY BE CALLED TO VERIFY EMPLOYMENT PER PROGRAM GUIDELINES

 

                      Parent/Guardian A                                                                                                                                                                                                                                                                              

Name of Employee:                                                       Position:                                                                                                      

 

Employer:                                                                     Phone:

 

Supervisor:

 

Address:

 

By signing, I give my permission for State Preschool to contact the above.

 

Signature of Parent/Guardian:___________________________________  Date:________

 

                      Parent/Guardian B

 

Name of Employee:                                                       Position:                                                                                                       

 

Employer:                                                                     Phone:

 

Supervisor:

 

Address:

 

By signing, I give my permission for State Preschool to contact the above.

 

Signature of Parent/Guardian:___________________________________  Date:________

                                                                                                                                                                                                                                                                                                             

 

For office use onlyIncome Verified By Employer

 

Person Contacted:

Parent A: _________________________________________________________________

 

Parent B: _________________________________________________________________

 

Gross Monthly Income Verified:

 

Parent A: _________________________________________________________________

 

Parent B: _________________________________________________________________

 

By:  ____________________________________________ Date: _____________

Revised 7-24-13