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Employment Wage Verification For use with Medicaid applications This form is used to verify employment information for Medicaid eligibility. Please complete the form and attach any supplemental paystubs, W-2s, or tax returns. Both the employee (client) and employer must complete and sign their sections. • If you are paid weekly: Provide the last 6 pay stubs • If you are paid bi-weekly: Provide the last 4 pay stubs • If you are paid monthly: Provide the last 4 pay stubs Release of Information: I authorize the employer below to release employment information to the US Virgin Islands Department of Human Services for purposes of determining eligibility for Medicaid. Client or Authorized Representative Printed Name Client or Authorized Representative Signature Client Perjury Statement: Under penalty of perjury, I certify that the information presented in this document is true and accurate to the best of my knowledge. By signing below, I understand that providing false statements may result in termination, denial, or recovery of benefits. Applicant Name Case Number Date Date of Birth Home Address Mailing Address Phone Number Email Date Client Signature Date Client Printed Name OR Authorized Representative Signature Authorized Representative Name Phone Number Email Date SIGN SIGN SIGN Disclaimer: We do not discriminate on the basis of race, ethnicity, color, national origin, religion, sex, age, or disability. Free language assistance services are available for people whose primary language is not English. We also provide free aids and services to assist with communicating the information effectively (such as interpreters, captioning, Braille, or large print). If you need these services, please contact us by phone or email. St Thomas/St. John District: 340-774-0930 ext. 4104 or sttjmap@dhs.vi.gov | St. Croix: 340-772-7100 or stxmap@dhs.vi.gov Privacy Notice: The information provided on this form will be used only for purposes of determining and verifying Medicaid eligibility. Your information is protected under state and federal privacy laws. Paystub 1 Paystub 2 Paystub 3 Paystub 4 Paystub 5 Paystub 6 Pay Date Pay Period Ending Gross Earnings Social Security Income Tax Medical Insurance Total Deductions NET PAY FOR OFFICE USE ONLY What is the employees’ start date? Did their employment end? If so, please provide the date employment ended and when they will receive their last pay. How often is the employee paid? Weekly Bi-weekly Monthly If other: Does the employee receive tips or gratuity? If Yes, how much do you receive weekly/bi-weekly/monthly? If additional space is needed, you may attach extra sheets of paper or additional copies of this form. Once all fields have been filled out, the form may be submitted in-person, by email, or by mail. Employer Information: Company/Employer Name Phone Mailing Address Email This is to certify that is employed by the company. The following information is true and correct to the best of my knowledge. Yes No Employer’s Printed Name Title Employer’s Signature Today’s Date SIGN