Case number:
Date:
TEXAS HEALTH AND HUMAN SERVICES COMMISSION
P O BOX 149027
AUSTIN, TEXAS 78714-9027
Need help? Call 2-1-1 or
1-877-541-7905
Fax: 1-877-447-2839
Mail: TEXAS HEALTH AND HUMAN SERVICES
COMMISSION
P O BOX 149027
AUSTIN, TEXAS 78714-9027
If you are deaf, hard of hearing, or speech
impaired, call 7-1-1 or 1-800-735-2989.
All numbers are free to call.
H1028
04/2015
Page 1
Note to :
This form is for your employer. They need to fill out the form and return it by
allow HHSC to give my Social Security number (SSN) to the employer listed on this form.
My SSN can be used to get facts about my employment. I also allow the employer listed on this form to give facts asked on this form to HHSC.
Sign here Date
. You must agree to let them give facts about you.
Fill out and sign this agreement:
I, (print your name)
Employer -- your help is needed:
We need proof that the following person is or was your employee.
Employee or former employee Social Security number
Some employers might get tax refunds or tax credits for hiring people who get certain state benefits.
To learn more, go to TexasWorkforce.org/wotc or email the Texas Workforce Commission at wotc@twc.state.tx.us.
Employer -- please follow these steps:
This person lives in a home in which someone is applying for state benefits. We need to know the amount of money this person makes or made
from this job.
1. Please fill out the “Proof of Employment” form on the next page.
2. If a question doesn't apply, mark it with "N/A."
3. Return the form by
To send this back to us, you can either: (a) give it to the employee listed above,
(b) mail it in the pre-paid envelope, or (c) fax it to 1-877-447-2839.
Texas Health and Human Services Commission
Proof of Employment
To be filled out by the employer
Case number :
2. Company or employer address - street, city, state, ZIP:
3. Employee name (as shown on your records):
4. Employee address (as shown on your records) - street, city, state, ZIP:
5. Is or was this person your employee?
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."
Yes No
6. Date hired: 7. Date of first check:
8. What type of job does or did this person have?
9. This job is or was (mark all that apply):
Full Time
Part time
Permanent
Temporary
10. Average hours per pay period:
11. Rate of pay: $ per:
Hour
Day
Week Month
Job
12. How often paid:
13. Does or did this person get overtime pay?
15. Is or was this person on leave without pay?
14. FICA or FIT withheld?
Daily Once a week Every 2 weeks
Twice a month
Once a month
Other:
Yes - often Yes - rarely
No - never
Yes
No
Yes
No
If yes: Start date of leave: End date of leave:
16. Does this person have a profit sharing or pension plan?
Yes
No
If yes: What is the current value? $
17. Does your company offer health insurance?
Yes
No
If yes: This person is:
Not enrolled
Enrolled with family members
Enrolled for self only
If yes: Name of insurance company:
18. Do you expect any changes to the facts above within the next few months?
Yes No
If yes: Explain what will change:
19. On this chart, list all money this person got from jobs or training (Need more room? Add pages with the same facts):
Date pay period
ended
Date
received
Actual hours
Gross pay amount
(before taxes taken out)
Other pay(include tips, commissions,
and bonuses)
EITC Advance amount
20. If you entered an amount in the "Other pay" column on the chart, tell us when and how often this person gets this other pay:
21. Does this person still work for you?
Yes No
If no: Date separated: Reason for separation:
Date of last check sent: Gross amount of last check sent: $
Employer - read, sign, and date:
I confirm that this information is true and correct to the best of my knowledge:
Employer -sign here Date
Title Phone number
1. Company or employer name:
H1028
04/2015
Page 2
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