Applicant must complete the top section only of this verification. Please return this completed section with your application.

RE: ___________________________________________________

Applicant Social Security No.: ________________________________

APPLICANT'S ADDRESS: ________________________________

NAME OF EMPLOYER:  __________________________________

ADDRESS OF EMPLOYER:________________________________

PHONE NUMBER OF EMPLOYER:_________________________

FAX NUMBER OF EMPLOYER: _______________________________________________________

To Whom It May Concern:

I would like the requested information regarding my wages furnished to the Redevelopment Authority of the County of Cumberland as soon as possible.

_____________________________        _______________________

Signature                                                    Date

******************************************************************************

Date Employment Began

2. Base Pay(current)$___________ annual 3. Earnings: year to date past year

$____________ monthly                         Base pay $____________ $____________

$____________ weekly                         Overtime $____________ $____________

$____________ hourly                           Commissions $_________ $____________

                                                                Bonus $_____________ $____________

4. Number of hours worked per week ____________5. Anticipated increase or decrease in salary in next 12 months_______________ 6. Anticipated overtime hours to be worked in next 12 months _________

___________________________________    ______________________

Signature/Title                                                    Date

__________________________________________________________________

Please print name and title

Cumberland County Redevelopment Authority

114 North Hanover Street, Carlisle, PA 17013

Tel. 717-249-0789