Name and Address
Form H1028 / 11-2018
Office Address, Area Code and Telephone No.
Area Code and Fax No.
Employee and Household Member Social Security No.
This individual is a member of a household applying for assistance from the Texas Health and Human Services Commission or
has income that affects another household's application for assistance. To determine the household's eligibility, it is necessary to
verify all earnings. Since this person is (or was) your employee, your help is needed.
Here's How You Can Help: Please provide the information requested on the back of this letter. Please ensure that all information
is complete and correct, since it will affect someone's eligibility and benefits. If a question does not apply, mark it N/A. After you
complete the form, give it to your employee or mail it in the envelope provided -or you may Fax it to the number listed above.
This information is needed by
. Please send it before this date.
Notice To Employers: You may be eligible for a tax refund, credit or both for hiring recipients who receive TANF or food stamp
benefits. For more information contact the Texas Workforce Commission, Work Opportunity Tax Credit Unit at 800-695-6879.
Thank you for helping. If you have questions, please feel free to call.
Case Name Case No.
I, give my permission to release the information requested on this form.
Form H1028
Page / 11-2018-E
Employment Verification
Employee Name (as shown on your records)
Employee Address (Street, City, State, ZIP Code - as shown on your records)
Is (or was) this person employed by you?
Yes No
If yes, what type of job?
Permanent Temporary
If no: Stop here – sign and date the bottom of this form and return it.
If yes: Answer all the questions below. If a question doesn’t apply, write “N/A
Rate of Pay
How Often Paid? Average Hrs. per Pay Period
Yes No
Overtime Pay
Frequently Rarely Never
FICA or FIT withheld
Yes No
Profit Sharing/Pension Plan
Yes No
If yes, current value
Health insurance available?
Yes No
If yes, employee is:
Enrolled with
Family Member
Enrolled for
Self Only
Name of insurance Company
Date Hired Date first check received Average hours per Week
If Employee is/was on
Leave Without Pay:
Start Date End Date
Do you expect any changes to the above
information within the next few months?
Yes No
If yes, explain:
On the chart below, list all wages received by this employee during the month(s) of:
Date Pay Period Ended
Date Employee
Received Paycheck Actual Hours Gross Pay
Other Pay*
(tips, commissions, bonuses) EITC Advance
* Please explain (in comments section below) when and how often tips, commissions, or bonuses are received.
If this person is no longer in your employ:
Date Separated Reason for Separation Date Final Check Received Gross Amount of Final Check
Company or Employer Address (Street, City, State, ZIP code)
This information is true and correct to the best of my knowledge and belief.
Signature – Person Verifying this Information Date
Title Area Code and Telephone No.