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The above-named individual has applied to this office for assistance. We ask your cooperation with providing information regarding their employment with you. We request this information pursuant to 22 M.R.S.A. § 4314. Any other information you can provide is appreciated. Please feel free to use the back of this form.
Social Services Staff
Please Fill Out the Items Below That Are Checked
Date First Worked:
Date and amount of first paycheck:
Date last worked for you:
Date and amount of last paycheck:
Date and amount of any future/outstanding paycheck:
Reason for separation:
Is Worker’s Compensation claim pending?
(Please type your name as a signed agreement)
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