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
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Name of Employee: Position:
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Employer: Phone:
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Supervisor:
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Address:
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By signing, I give my permission for State Preschool to contact the above.
Signature of Parent/Guardian:___________________________________ Date:________ |
Parent/Guardian B
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Name of Employee: Position:
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Employer: Phone:
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Supervisor:
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Address:
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By signing, I give my permission for State Preschool to contact the above.
Signature of Parent/Guardian:___________________________________ Date:________ |
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For office use only: Income Verified By Employer |
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Person Contacted: Parent A: _________________________________________________________________
Parent B: _________________________________________________________________
Gross Monthly Income Verified:
Parent A: _________________________________________________________________
Parent B: _________________________________________________________________
By: ____________________________________________ Date: _____________ |
Revised 7-24-13