Form W-532 (page 1) (LDSS-3707)

Rev. 8/16/11

Date:
Case Number:
Case Name:
Caseload:
Worker Name:
Worker Phone:
c Applicant g
Check one: g
d
e
f c Participant
d
e
f

Address:

Past/Present Employer:

Abstract of Section 143 of the New York State Social Service Law: "Employers are required to furnish the Human Resources
Administration (HRA) with information regarding wages, salaries, earnings or other income of any applicant for, or participant
of, assistance or of any relative legally responsible for the support of such person."

We are currently reviewing the assistance case of the above named person. In order to complete our review, we need
information concerning the wages of , Social Security number ,
(name of employed person)
Date of Birth , received for the period from to .
(date) (date)
Please complete both sides of this form; include information for any periods during which the employee received sick pay,
vacation pay, and/ or compensation pay. A copy of the employee's pay ledger or a computer printout of the pay record is
acceptable, as long as all of the requested information is clearly presented. If this person is no longer working for you, please
complete only the reverse of this form using his/her last week's earnings received.
Please complete and return this form by .
(date)

Check Pay Period Gross Pay EIC* Health Number of Actual Hours
Release (Excluding Insurance Hours Worked
Date From To EIC*) Deductions Scheduled to
Work

NOTE: FOR THOSE WITH TIP INCOME, PLEASE INCLUDE TIPS IN THE GROSS PAY COLUMN.
* Earned Income Credit
We thank you for your cooperation.

(see reverse side)

Form W-532 (page 2) LDSS-3707 Human Resources Administration
Rev. 8/16/11 Family Independence Administration

Employer Questionnaire
EMPLOYEE INFORMATION
Employee Name Social Security Number

Home Address While in Your Employ

Date Employment Began Position

Date Employment Ended Reason for Leaving

PAYROLL INFORMATION
Rate of Pay $ c
d
e
f
g Hourly c Weekly g
d
e
f
g c Bi-weekly g
d
e
f c Other
d
e
f Hours per week Number of Exemptions
Miscellaneous Payments Date Paid Deductions $ Life Insurance $
Overtime Pay $ Earned Income Credit $ Disability Insurance $
Comp. Pay $ Federal Income Tax Withheld $ Payroll Savings
Vacation Pay $ NYC Tax Withheld $ g Bonds
c
d
e
f g Credit Union
c
d
e
f
Sick Pay $ FICA Deduction $ c IRA
d
e
f
g c Other (specify below)
d
e
f
g
Pension $ Pension $ c 401K
d
e
f
g
Name of Union from which the person may Union Dues $ Other Payroll Deductions:
receive benefits:
Health Insurance $

HEALTH INSURANCE INFORMATION

c No g
Does/did employee have health insurance? g
d
e
f c Yes
d
e
f If Yes, through employer? c
d
e
f
g through union? c
d
e
f
g
Name of Carrier Policy or ID Number Group Number

Date of Coverage
Names of Covered Individuals
From To

If no longer in you employ, is health insurance coverage still available? g No f

c
d
e
f g Yes
c
d
e
If Yes, can policy be converted to an individual policy? c No g
d
e
f
g c Yes
d
e
f If Yes, cost of conversion to employee $ per
Types of coverage when in your MAJOR IN-PATIENT SENIOR OUT- DRUG/ HOME NURSING
employ: DENTAL OPTICAL
MEDICAL HOSPITAL CARE PATIENT PHARMACY CARE HOME
(Check gb appropriate code)
c
d
e
f 1 2 3 4 5 6 7 8 9

LIFE INSURANCE INFORMATION

c No f
Does/did employee have life insurance? g
d
e
f g Yes
c
d
e If Yes, through employer? c
d
e
f
g through union? c
d
e
f
g
Name of Carrier Policy or ID Number Group Number

Date of Coverage
Names of Covered Individuals
From To

Completed by:

Company/Organization Name Address

Signature Date Employer ID Number

Name (print) Title Telephone Number