An Equal Opportunity Employer EMPLOYMENT VERIFICATION FORM An application for Economic Support benefits was submitted to the Georgia Crime Victims Compensation Program (CVCP) for consideration. To help the CVCP make the best possible decision in determining eligibility, we would appr eciate your assistance by providing the below information. Employee/Victim Address: SSN: Claim Number: PLEASE NOTE: TO BE VALID , T his form must be attached business card that includes the business contact information AND the documents must be faxed or mailed by the EMPLOYER . Date of Victimization: 1. Dates of employment: From: // To: // 2. Hourly Wage: $ Annual Salary: $ Employment type: Full - time Part - time Number of hours worked per week 3. Work dates missed due to victimization, OR From: // To: // employee/victim did not miss any days from work: Check here if no work days missed 4 . Total amount of wages lost due to victimization. $ 5. Dates of paid leave: None Annual Sick Sick & Annual Other: From: // To: // 6. Disability pay: Yes No If Yes, what type: Short - Term Long - Term Amount: $ Dates of disability pay: From: // To: // Company Name (print name) Employer (print name) Employer Signature Date: // Telephone No.: - - American LegalNet, Inc. www.FormsWorkFlow.com