2134 Rimrock Road, P.O. Box 7843, Madison, WI 53707-7843 (608) 266-1311 | 1-800-WIS-VETS (947-8387)
REQUEST FOR VERIFICATION OF EMPLOYMENT
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04(1)(m)].

Wis. Stats. Chapter 45 Instructions: Lender — Complete items 1 through 7. Have applicant complete item 8. Forward directly to employer named in item 1. Employer — Please complete either Part II or Part III as applicable. Sign and return directly to lender named in item 2.
Part I - Request
1. To (Name and address of employer)	2. From (Name and address of lender)
3. Signature of Lender	4. Title	5. Date	6. Lender’s Number (Optional)
I have applied for a benefit and state that I am now or was formerly employed by you. My signature below authorizes verification of this information.
7. Name and Address of Applicant (Include employee or badge number)	8. Signature of Applicant
Part II - Verification of Present Employment
Employment Data	Pay Data
9. Applicant’s Date of Employment	12A. Current Base Pay (enter Amount and Check	12C. For Military Personnel Only
Period) Annual Hourly	Pay Grade
Monthly Other	Type	Monthly Amount
10. Present Position	$__________ Weekly (Specify)	Base Pay	$
12B. Earnings	Rations	$
11. Probability of Continued Employment	Type	Year to Date	Past Year	Flight or Hazard	$
13. If Overtime or Bonus is Applicable,	Base Pay	$	$	Clothing	$
is its Continuance Likely?
Overtime	$	$	Quarters	$
Overtime Yes No
Commissions	$	$	Pro Pay	$
Bonus Yes No	Bonus	$	$	Overseas or Combat	$
14. Remarks (If paid hourly, please indicate average hours worked each week during current and past year)
Part III - Verification of Previous Employment
15. Dates of Employment	16. Salary/Wage at Termination Per (Year) (Month) (Week) Base _________ Overtime _________ Commissions _________ Bonus _________
17. Reason for Leaving	18. Position Held
19. Signature of Employer	20. Title	21. Date
The confidentiality of the information you have furnished will be preserved except where disclosure of this information is required by applicable law. The form is to be transmitted directly to the lender and is not be transmitted through the applicant or any other party.