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Form 241
Revised 8/14
Letter to Verify Employment
The employer may submit a statement, on company letterhead, for verification.
The statement must include:
1) The name of the individual receiving the income
2) The gross amount of income received
3) The frequency of income received (i.e. weekly, every two
weeks, twice a month, monthly or annually)
A sample letter could be written as follows:
This statement is to confirm that _______________________ is employed at
Name of Employee
Name of Employer
______________________ received a gross income (before deductions for
Name of Employee
taxes, social security, insurance, etc.) of $______________ on ___/___/___.
The frequency of payment is:
Weekly Every two weeks Twice a month Monthly Annually
________________________/_____________ __________________
Signature of Employer Title Date
___________________________________ (____)______________
Address State Zip Code Telephone Number
The U.S. Department of Agriculture prohibits discrimination against its customers, employees,
and applicants for employment on the basis of race, color, national origin, age, disability, sex,
gender identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or
parental status, sexual orientation, or all or part of an individual’s income is derived from any
public assistance program, or protected genetic information in employment or in any program or
activity conducted or funded by the Department. (Not all prohibited bases will apply to all
programs and/or employment activities.) If you wish to file a Civil Rights program complaint of
discrimination, complete the USDA Program Discrimination Complaint Form, found online at, or at any USDA office, or call (866) 6329992
to request the form. You may also write a letter containing all of the information requested in the
form. Send your completed complaint form or letter to us by mail at U.S. Department of
Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C.
20250-9410, by fax (202) 690-7442 or email at [email protected]. Individuals who are
deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay
Service at (800) 877-8339; or (800) 845-6136 (Spanish). USDA is an equal opportunity provider
and employer.
Letter to Verify Employment
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