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Faxed to: "Caseworker's Name"

The following information is provided in response to your request on: 7/6/2008

The employer provided this information to The Work Number to act as their official agent for employment and income verification. Any inconsistency between the most recent start date and the total time with the employer is due to prior work period. If you have any questions, please call our Client Service Center at 1-800-996-7566 (Voice) / 1-800-424-0253 (TTY/Deaf).

Information not provided by the employer is shown as "Data Not Provided." Employment and Income information current as of 12/16/1899
Reference Number for this verification: 10639911


EMPLOYER
Employer: 90001 - Enterprise Test Co.
Employer Headquarters Address: 2234 Main Street
  St. Louis, MO 63146
Federal Employer Identification Number (FEIN): 123456789

EMPLOYEE
Employee: Randy W. Doe
Social Security Number: 111-00-3341
Address: 1545 Orangedale Lane
  St. Louis, MO 63122
Date of Birth: 12/03/62

EMPLOYMENT
Employment Status: Active
Most Recent Start Date: 2/01/99
Original Hire Date: 2/1/99
Total Time with Employer: 3 years, 6 months
Job Title: Clerk
Union Affiliation: None
Work Location (Job Site): 1850 Borman Court
  St. Louis, MO 63146

* MEDICAL INSURANCE
Medical Insurance Available: Yes
Employee Eligible: Yes
Reason for Ineligibility: None
Employee Enrolled: Yes
Eligibility Date: 5/01/99
Coverage Start Date: 5/01/99
Coverage Termination Date: Data Not Provided
Medical Carrier Name: United Healthcare
Medical Carrier Address: Data Not Provided
Medical Carrier Phone Number: 314-214-7000
Medical Insurance Policy Number: 111-00-3341-01
Medical Carrier Group Number: GN-0098
Coverage Level: Data Not Provided
Annual Cost for Medical Insurance: Data Not Provided
Dependent Coverage Available: Yes
Per Pay Period Cost to Add Dependent: $10
Number of Dependents Covered: 2
Dependents Covered: 2

Dependents SSN Birth Date
John R. Doe 111-00-3341 03/04/95
Suzie M. Doe 842-00-2237 11/27/98

Participating in Medical COBRA:

Data Not Provided

* DENTAL INSURANCE
Dental Insurance Available: YES
Employee Eligible: YES
Employee Enrolled: YES
Dental Carrier Name: Delta Dental
Dental Carrier Phone Number: 314-214-7000
Dental Insurance Policy Number: 1023345

* VISION INSURANCE
Vision Insurance Available: YES
Employee Eligible: YES
Employee Enrolled: NO
Dental Carrier Name: Data Not Provided
Dental Carrier Phone Number: Data Not Provided
Dental Insurance Policy Number: Data Not Provided

* WORKERS' COMPENSATION
Receiving Workers' Compensation: Yes
Carrier: GatesMcDonald
Date of Injury: 2/22/01
Date of Award: 6/05/01
Claim Number: 12345
Claim Pending: No

INCOME AND DEDUCTIONS
Average Hours per Pay Period: 80
Rate of Pay: $9.00 hourly
  2002 2001 2000
Total Gross: 9,850.00 18,150.00 18,150.00
Payroll Deduction For All Insurance Coverage:     40.00

PAY PERIOD DETAIL 12/16/1899
Income Withholding
Total Gross Earnings 720.00 Federal Tax 108.90
Pension 0.00 State Tax 25.40
Other Income 0.00 Local Taxes 11.40
    State Tax 25.40
    Social Security 43.20
    Medicare 9.42
    Retirement / 401K 40.00
    Cafeteria Plan 10.50
    Garnishments 0.00
    Other Withholding 0.00
    Net 514.38
Pay Pd. Date Pay Date Hours Wkd. Gross Net
12/16/1899 12/20/1899 80.00 720.00 514.38
12/2/1899 12/5/1899 80.00 720.00 514.38
11/18/1899 11/21/1899 80.00 720.00 514.38
11/4/1899 11/7/1899 60.00 540.00 383.40
10/21/1899 10/24/1899 80.00 720.00 514.38
10/7/1899 10/10/1899 70.00 630.00 447.30

* Please note that medical, dental, vision, and workers' compensation benefits are provided in some but not most verifications.

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