Evidence of chore and personal care service wages may be obtained by completing and
faxing the DSHS wage verification form shown in the EXHIBIT below to (360) 664-6103.
EXHIBIT
Request for Wage Verification for In-Home Supportive Services from DSHS of Washington
Attention: VOE
Date: ________________
DSHS, SSPS
P O Box 45812
Olympia, WA 98504-5812
DSHS PHONE (360) 664-6161
DSHS FAX (360) 664-6103
NH Name: ___________________________ [ ] TII [ ] TXVI [ ] Both
NH SSN: __________________________
Reason for Request: [ ] Initial Claim [ ] Redetermination
[ ] S2/K6/K7 Alert [ ] CDR
Social Security Administration is requesting wage verification on:
Name of Employee __________ __________ ___________ AKA _____________
Employee's Address _________________________________________________
_________________________________________________
Employee's SSN __________________ SSPS Vendor Number _____________
SSPS Provider Number ____________________
Wage verification is needed for: [ ] 2003 [ ] 2004 [ ] 2005 [ ] 2006 [ ] 2007
Verification is not available for periods prior to January 1997.
Remarks: _________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
Please return the requested information to:
Social Security Administration
Attention: ________________________ FAX: (____)____________________
Address: _________________________ Phone: (____)__________________
___________________________________ Extension: ___________________
RO. WA Wage Ver. 07/07