Fillable Date Caseworker Office Address and Telephone No. (Your Texas Benefits)

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Date Caseworker Office Address and Telephone No. (Your Texas Benefits)

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  • 16 check-boxes
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Bilingual phrase English Form HEADER A
Bilingual phrase English Form HEADER B
Date
Caseworker
Office Address and Telephone No.
Request for Domicile Verification
Name of Client Case No.
Address
The person listed above has told us that you are not related to them but are familiar with their family. To help us correctly evaluate the
household's situation, we need your assistance.
Please complete the information requested on page 2 of this letter and return it to me in the postage paid envelope provided. Please
return it as soon as possible, but no later than
Date
Your help is greatly appreciated.
Form H1155 / 01-1995-E
Form H1155
Page 2 / 01-1995-E
Domicile Verification
(The form must be completed by a nonrelative who does not live with the client.)
Please list all of the persons living in the home, including the client named on the front of this form:
Name Relationship to Client Name of Employer
Name of Client
I can verify the above information because I am:
A Neighbor An Employer A School Official A Clergyperson A Friend A Landlord
A Child Care Provider Other (explain):
How long have you known the family?.....................................................................................
Years Months Weeks
X
Signature
Date
Name
Address Telephone
Bilingual phrase English Form FOOTER C
Bilingual phrase English Form FOOTER D
click to sign
signature
click to edit
Bilingual phrases, Spanish forms HEADER A
Bilingual phrases, Spanish forms HEADER B
Fecha
Trabajador de casos
Dirección y número de teléfono de la oficina
Solicitud de verificación de dirección
Nombre del cliente
Número de caso
Dirección
La persona indicada antes nos dijo que no hay parentesco entre ustedes, pero que usted conoce a su familia. Necesitamos su ayuda
para poder evaluar correctamente la situación del hogar.
Por favor, dé la información que se pide en la página 2 de esta carta y devuélvamela en el sobre adjunto. No necesita estampilla. Por
favor, devuélvala lo antes posible, a más tardar el
Fecha
Agradecemos mucho su ayuda.
Formulario H1155-S / 01-1995-E
Formulario H1155-S
Página 2 / 01-1995-E
Verificación de dirección
(Una persona que no es pariente del cliente y que no vive con él debe llenar este formulario.)
Por favor, haga una lista de todas las personas que viven en el hogar. Incluya el nombre del cliente que aparece al otro lado de
este formulario.
Nombre Relación con el cliente Nombre del empleador
Nombre del cliente
Puedo verificar la información anterior porque yo soy:
Vecino Empleador
Funcionario de la escuela Clérigo
Amigo
Dueño de la casa
Proveedor de cuidado de niños
Otro (explique):
¿Cuánto hace que conoce a esta familia? ...............................................................................
Años Meses Semanas
X
Firma
Fecha
Nombre
Dirección
Número de teléfono
Bilingual phrases, Spanish forms FOOTER C
Bilingual phrases, Spanish forms FOOTER D
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signature
click to edit
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Date Caseworker Office Address and Telephone No. (Your Texas Benefits)

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Completed 16 April 2022

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