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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
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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?
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