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INCOME VERIFICATION LETTER In order for to complete his/her eligibility determination so that he/she may receive services at the clinic, the bottom portion of this letter needs to be completed and returned to us. We appreciate your cooperation in this matter and wish to assure you that all information you give us will be kept confidential. Employee name: Date employment began: Hours of work per week: Amount paid per hour: Company name: Supervisor’s name: Supervisor's signature: Company’s address: Company's phone number: