Employee Attestation Form

Employee Attestation Form - Instead, employees are typically asked to complete and sign a form confirming their status. An employee is not able to claim bonuses independently. Employer or authorized representative review and verification. Employer information (to be completed by the employer) employer name: Web you, the employee, must complete each field in section 1 as described below. Newly hired employees must complete and sign section 1 no later than the first day of employment. Have the employee complete section 1 at the time of hire (by the first day the employee starts work for pay or other remuneration) by entering the correct information and signing and dating the form. See specific eligibility requirements and claiming guidance available through the hwb webpage: The employer must maintain contemporaneous records for all claims related information and any other data or documents used to demonstrate that an employee was eligible to receive such bonus, including but not limited to employee attestations. ________________________ employer mmis (or sfs) number:

The following attestations will be required for a complete claim submission: ________________________ employer mmis (or sfs) number: Employer information (to be completed by the employer) employer name: Web worker bonus (“hwb”) for the employer. Web completing section 1, employee information and attestation. Have the employee complete section 1 at the time of hire (by the first day the employee starts work for pay or other remuneration) by entering the correct information and signing and dating the form. Section 1 should never be completed before you have accepted a job offer. Web qualified employers are required to claim the bonus on behalf of their employees. Instead, employees are typically asked to complete and sign a form confirming their status. Employer attestation form (pdf) employee attestation form (pdf)

Have the employee complete section 1 at the time of hire (by the first day the employee starts work for pay or other remuneration) by entering the correct information and signing and dating the form. The employer must maintain contemporaneous records for all claims related information and any other data or documents used to demonstrate that an employee was eligible to receive such bonus, including but not limited to employee attestations. Web qualified employers are required to claim the bonus on behalf of their employees. Employer or authorized representative review and verification. ________________________ employer mmis (or sfs) number: Web worker bonus (“hwb”) for the employer. Web 3.0 completing section 1: Web eligible employees must complete this employee attestation form in order to receive a bonus. Web completing section 1, employee information and attestation. ________________________ this attestation applies to the following vesting period:

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Web 3.0 Completing Section 1:

Web you, the employee, must complete each field in section 1 as described below. Web eligible employees must complete this employee attestation form in order to receive a bonus. Instead, employees are typically asked to complete and sign a form confirming their status. Employer information (to be completed by the employer) employer name:

The Following Attestations Will Be Required For A Complete Claim Submission:

________________________ employer mmis (or sfs) number: Section 1 should never be completed before you have accepted a job offer. Employer attestation form (pdf) employee attestation form (pdf) Web qualified employers are required to claim the bonus on behalf of their employees.

________________________ This Attestation Applies To The Following Vesting Period:

An employee is not able to claim bonuses independently. The employer must maintain contemporaneous records for all claims related information and any other data or documents used to demonstrate that an employee was eligible to receive such bonus, including but not limited to employee attestations. See specific eligibility requirements and claiming guidance available through the hwb webpage: If the employee enters the information by hand, ensure the employee prints.

Newly Hired Employees Must Complete And Sign Section 1 No Later Than The First Day Of Employment.

Employer or authorized representative review and verification. Web worker bonus (“hwb”) for the employer. Web completing section 1, employee information and attestation. Have the employee complete section 1 at the time of hire (by the first day the employee starts work for pay or other remuneration) by entering the correct information and signing and dating the form.

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