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2. Date:
4. Re:
6. Dear Employer:
   
   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.
   
   Sincerely,
   
   Social Services Staff
8. Please Fill Out the Items Below That Are Checked
10. Date First Worked:
11. Part-Time:
12. Full-Time:
14. Date and amount of first paycheck:
16. Date last worked for you:
18. Date and amount of last paycheck:
20. Date and amount of any future/outstanding paycheck:
22. Reason for separation:
24. Is Worker’s Compensation claim pending?
26. Signed
    (Please type your name as a signed agreement)
27. Company Name
28. Address
29. Telephone
Leave This Blank:


31. 1. Receive an email copy of this form.
32. Email address

    This field is not part of the form submission.

33. Submit

* indicates a required field