Fillable Printable Proof of Employment From

Proof of Employment From

PROOF OF EMPLOYMENT FORM

This form will need to be submitted each month by approved recipients as proof of continued employment as

an eligible prosecutor or public defender.

OFFICE OF PUBLIC ADVOCACY

JOHN R. JUSTICE (JRJ) PROGRAM

PROOF OF EMPLOYMENT FORM

MONTH & YEAR:

RECIPIENT NAME:

Fiscal Year Grant:

SECTION A: EMPLOYMENT INFORMATION

Employer Name:

Supervisor Name: Title:

Supervisor Telephone #:

Supervisor Fax #:

Supervisor Email:

SECTION B: EMPLOYMENT SERVICE

Position Title:

Hire Date: Position Status:

SECTION C: CERTIFICATION

I certify that all information provide above is true and accurate as of this date. I acknowledge that falsified

information could result in the termination of such contract under the JRJ Program.

Applicant Signature: Date:

I certify this individual is a current employee of the above referenced agency and that all information

provided is true and accurate as of this date.

Supervisor Signature: Date:

Submit by the 5

of each mon th b y email to beth.g[email protected]ov or by fax to (907) 269-1071.

Attach Statement Due Sheet from lending institution as well for proof of loan payment information.