Tamika Joseph

• To be filled out by the employer 6
• Date hired: 8
• What type of job does or did this person have? 9
• This job is or was (mark all that apply): Full Time 10
• Average hours per pay period: 11
• Rate of pay: $ 12
• How often paid: 1
• Company or employer name: Benson Momah - Blessing Health Care 2
• Company or employer address - street, city, state, ZIP: 3
• Employee name (as shown on your records): 4
• Employee address (as shown on your records) - street, city, state, ZIP: 5
• Is or was this person your employee?
• Yes
• No
• If no: Stop here - sign and date the bottom of this form and return it
• If yes: Answer all the questions below
• If a question doesn't apply, write "N/A." 7
• Date of first check: per:
• Hour
• Daily
• Twice a month 13
• Does or did this person get overtime pay?
• Once a week
• Once a month
• Day 14
• FICA or FIT withheld
• Yes
• No 15
• Is or was this person on leave without pay
• Yes
• Yes - often
• If yes: What is the current value
• 17
• Does your company offer health insurance
• Yes
• Employer -sign here 21
• Does this person still work for you
• Yes
• If no:
• Date separated:
• Date of last check sent:
• Texas Health and Human Services Commission
• Case number :
• No
• If yes: Start date of leave:
• End date of leave: 16
• Does this person have a profit sharing or pension plan
• Yes No
• Part time
• Date pay
• Date Actual Gross pay amount period ended received hours (before taxes taken out)
• No
• No
• Week
• If yes: This person is:
• Not enrolled
• Enrolled with family members
• FUN
• If yes: Name of insurance company: 18
• Do you expect any changes to the facts above within the next few months
• Yes
• Date 1015828426
• Permanent
• Every 2 weeks
• Other:
• Yes - rarely
• Month
• If yes: Explain what will change: 19
• On this chart, list all money this person got from jobs or training (Need more room
• Add pages with the same facts):
• Reason for separation:
• Job
• Other pay (include tips, commissions and bonuses)
• Employer - read, sign, and date:
• I confirm that this information is true and correct to the best of my knowledge:
• No 20
• If you entered an amount in the "Other pay" column on the chart, tell us when and how often this person gets this other pay:
• Temporary
• Title
• No - never
• Enrolled for self only
• Gross amount of last check sent: $
• EITC Advance amount
• Total Pretax
• Contributions
• T-01028-0688717947
• Phone number
• H1028 03/2021
• Page 2

The person I am I don't like being late missing days i received a 40 inch television at my old job and a 500 visa gift card for being ontime and not missing days for 2 years