Employment Verification Form – Pennsylvania

The Employment Verification Form (CY 925) is the Pennsylvania Department of Human Services form that a Child Care Information Services (CCIS) agency sends to an employer to verify an employee's employment, work schedule and employment income for the subsidized child care program.

The form has two kinds of content. At the top, the employee names the employer or place of employment and the immediate supervisor, and signs an authorization that lets the CCIS agency verify the information on the form. Under the heading stating that the following sections must be completed by the employer, the employer gives:

• the employer identification number (EIN), address of employment and telephone number;
• the employee's job title, start date and whether the employee is newly hired;
• hourly rate, gross pay, average daily tips, next pay date and pay frequency;
• a weekly work schedule, plus any schedule change, extended leave, temporary hire or seasonal break.

The cover letter addressed to the employer explains that the agency needs an accurate record of the employee's schedule and income, and the employer's signature block confirms that the information will be used to determine eligibility for subsidized child care. The form is not a pay statement and is not an application for child care assistance.

An authorized company representative completes the employer sections of this form for any employee who has asked for assistance paying child care costs and whose employment a CCIS agency must verify. The letter on the form is explicit: the representative must not be the employee.

• Employers: complete the employer identification number, address, telephone number, job title, start date, pay, schedule, leave and temporary or seasonal sections, then print your name and job title, sign and date.
• Employees: write the employer or place of employment and your immediate supervisor's name and title, then print your name, sign and date the authorization that lets the CCIS agency verify the information.
• Employers of employees with a varying schedule: give a 4-week sample schedule. Employers whose employee works the same schedule each week do not need to.

Employees should not fill in the sections reserved for their employer. Questions about how to complete the form go to the CCIS agency named on the letter.

The form is completed when an employee has requested help paying child care costs and the CCIS agency needs to verify employment with you. No due date is printed on the form itself, so ask the CCIS agency that sent it how quickly it needs the form returned.

Timing entries on the form itself include the employment start date, the next pay date and, where they apply, the effective begin date of a schedule change, the begin and return dates of extended leave such as maternity or disability leave, the last date of guaranteed employment for a temporary hire, and the last day of work before a seasonal break with the expected date of return.

The form is returned by mail directly to the Child Care Information Services (CCIS) agency; the letter on the form states that it must be mailed directly to the CCIS agency.

• By mail to the CCIS agency: the employer's representative mails the completed and signed form to the CCIS agency named in the CCIS line of the letter. The form itself prints no street address, so use the one the CCIS agency gives you.
• Questions: if you are unsure how to complete the form, contact the CCIS agency listed on the letter.

The form names no other channel and mentions no fee. Check that both signatures are present before mailing: the employee's authorization near the top and the employer's signature at the end. FillingPDF lets you fill out and download the PDF; submission follows the CCIS channels above.