Appendix XII, Examples of Methods to Verify Income and Resources

Revision 17-1; Effective March 15, 2017

Resources — CCSE Handbook Section 3420

Element	Verification Sources	Documentation
Bank accounts, checking, savings, certificates of deposit (CD), money market	Current bank statement Letter or contact with financial institution or bank Medicaid eligibility (ME) Form H1239 Current savings statements Recent entry in a savings passbook	Owner, if different from applicant's name Type of account Name and address of financial institution, if not listed on application Source of verification Account number, if not listed on application Account balance and date, if different from face-to-face contact If representative contacted, his name and telephone number
Bonds	Newspaper Bank or other financial institution Brokerage firm/securities firm Public library's research department For savings bonds, the U.S. Treasury Office or its publication that is used by banks and is available on request	Owner, if different from applicant's name Name of bond issuer and type of bond, if not listed on application Source of verification and date, if different from face-to-face contact Number of bonds and serial numbers (if applicable) Current market or cash value. Corporate and municipal bonds may be discounted so the cash value may be less than the face amount. Some U.S. savings bonds must be held for 60 days before being cashed. If representative contacted, his name and telephone number
Cash on hand, safe deposit boxes	Statement of individual	Statement of individual regarding the contents Date, if different from face-to-face contact
Notes and mortgages (exempt if buyer fulfilling the contractual obligations)	Statement of individual	Statement of individual regarding the current market value Date, if different from face-to-face contact
Real property (unless in probate) (If property is exempt because the individual is making a good faith effort to sell, then he must supply evidence of the attempt to sell and the worker must verify that the selling price is at fair market value.)	Tax bill or assessment notice Tax assessor Local real estate broker Local bank	Owner, if different from applicant's name Source of verification and date, if different from face-to-face date Current equity value of individual's interest If collateral used, pertinent name and telephone number
Revocable trust funds	Bank statement Trust agreement Will Trustee Bank representative	Name of trustee/beneficiary, if not listed on application Source of verification and date, if different from face-to-face date Accessibility of trust Amount held in trust If collateral used, pertinent name and telephone number
Stocks	Recent statement from Brokerage house Issuing company Securities firm Newspaper Public library's research department	Owner, if different from applicant's name Name of company Source of verification and date, if different from face-to-face contact Number and type of shares Market value Use the closing price on the day of application or recertification If collateral used, pertinent name and telephone number
Vehicles (if not eligible for exclusion)	"Blue" or National Automobile Dealers Association (NADA) Book (gold) Newspaper ads Auto dealer Finance company, or bank	Owner, if different from applicant's name Year, make, and model Source of verification and date, if different from face-to-face date Market value Equity value If collateral used, pertinent name and telephone number Assess $100 value for inoperable junk vehicle if individual's total resources are less than $4,900 for a single person or $5,900 for a couple
Work equipment (excluded if required for employment, self-employment, or self-support)	Individual's estimate of value Dealer	Owner, if different from applicant's name Description of property, if not on application Individual's estimate of value Equity value Source of verification and date, if different from face-to-face contact If collateral used, pertinent name and telephone number

Income Eligibility — CCSE Handbook Section 3300

Element	Verification Sources	Documentation
The individual's total earnings (monthly gross) Money Wages Salary Armed forces pay Commissions Tips Piece-rate payments Cash bonuses	Employer Oral statement Written statement Viewing check stubs Copies of earnings statements (check stubs)	Who is employed, if not indicated on application Name, address, telephone number of employer, if not on application Date verified, if different from face-to-face contact How information was verified If by telephone, include name and telephone number of the contact If by viewing, include description of document and date, if different from face-to-face contact Gross amount Frequency of pay Show your calculations
Net income from non-farm self-employment	Business receipts/records maintained by individual Most recent Internal Revenue Service (IRS) Form 1040 (Income Tax Return) (In instances where complete verification of self-employment income is impossible, accept the individual's word if the information seems reasonably valid.)	Who is self-employed, if not indicated on application Name and kind of business (address and telephone number if different), if not on application Date verified, if different from face-to-face contact Types of records used and period covered Amount of gross income Amount of expenses Costs of purchased goods Rent, heat, light, power Depreciation charges Wages/salaries paid Business taxes (not personal income taxes or Social Security taxes) If amount of net countable income is anticipated to be different, explain reason. Amount of net countable income and calculations used to arrive at countable income.
Net income from farm self-employment	Business receipts/records maintained by individual Most recent IRS income tax return Statements from other knowledgeable sources (e.g., county farm agent)	Who is self-employed, if not indicated on application Type of farm income, if not indicated on application Date verified, if different from face-to-face contact Type of records used and period covered Amount of gross income Value of products sold Government crop loans Money from rental of farm equipment to others Incidental money from the sale of wood, sand, gravel, etc. Note: Do not include value of fuel, food, or other farm products used for family living Amount of operating expenses Cost of feed, fertilizer, seed, and other farming supplies Cash wages paid to farmhands Depreciation charges Cash rent Interest on farm mortgages Farm building repairs Farm taxes (not personal income taxes or Social Security taxes) If amount of net countable income is anticipated to be different, explain reason. Amount of net countable income and calculations used to arrive at countable income.
Social Security (Retirement, Survivors, and Disability Insurance (RSDI)) Pensions Survivor's benefits Permanent disability insurance	Recent award letter Recent cost-of-living increase notice from the Social Security Administration (SSA) RSDI check or direct deposit slip WTPY response Form SSA 1610 (use only if no other source is available) Texas Department of Health and Human Services Commission (HHSC) computer inquiry Contact with SSA representative	Payee/beneficiary, if not indicated on application Gross benefit amount before deductions for Medicare insurance Claim number/suffix Date received, if different from face-to-face date Source of verification and date, if different from face-to-face contact If SSA representative contacted, name and telephone number
Railroad retirement (RR)	Form 1026 Recent award letter from RR Board Contact with representative of RR Board Most recent check or direct deposit slip	Payee/beneficiary, if different from applicant's name Gross benefit amount before deductions for Medicare insurance Claim number Date received Source of verification and date, if different from face-to-face date If RR representative contacted, name and telephone number
Dividends Stocks Membership in associations	Recent check stubs or checks Letter from company making payments Telephone contact with representative of company Recent statement from a brokerage house or the company issuing the stock to verify dividends	Payee/beneficiary, if different from applicant's name Payor (company) Source of verification and date Account number, if not listed on application Gross amounts Dates received Frequency Reason for dividend If company representative contacted, name and telephone number If excludable, reason for exclusion If countable, show calculations used to arrive at an average amount.
Net rental income House, store or other property Boarders or lodgers	Business receipts/records maintained by individual Most recent IRS income tax return Statements from individual and renter Copy of lease or rent check	Type of rental income, if not indicated on application Date verified, if different from face-to-face contact Types of records used and period covered Amount of gross income Amount of expenses Property tax receipts Mortgage payment interest Insurance payments Bills for repair and upkeep of property Note: Capital expenditures for additions or improvements and depreciation are not deductible If amount of income is anticipated to be different, explain reason. Amount of net countable income and calculations used to arrive at countable income.
Net income from lease of mineral rights Gross royalty payments Yearly lease payments	Royalty interest statements (check stubs) Contact with representative of oil company Check stub from lease payments	Name of payor/payee, if different from applicant's name Source of verification and date, if different from face-to-face date Account number Amount of yearly lease payments Gross amounts over past 12 months (royalty payments) Dates received Frequency If representative contacted, name and telephone number Deduction amounts Excise taxes Property taxes Note: Federal windfall profits taxes are not deductible—may have to add it back if company deducted it Amount of net countable income and calculations used to arrive at a 12-month average (royalty payments)
Income from mortgages or contracts (notes) Negotiable and Non-negotiable	Copy of contract Copy of document with the statement of terms of repayment Copy of recent check from payor Contact with bank representative Statements from the individual and payor	Name of payee/payor, if different from applicant's name Source of verification and date, if different from face-to-face contact Payment amount Frequency Date received If representative contacted, name and telephone number
Public assistance Temporary Assistance for Needy Families (TANF) Supplemental Security Income (SSI) General assistance from county or city Medicaid Qualified Medicare Beneficiary (MQMB) Qualified Medicare Beneficiary (QMB) only Specified Low-Income Medicare Beneficiary (SLMB) only Qualifying Individuals (QI) coverage Food stamps	HHSC computer inquiry Most recent SSI award letter or SSI check Most recent individual notice or check Contact with a representative Texas Works worker MEPD case specialist SSI representative City or county worker TANF case record	Name of recipient, if different from applicant's name Type of benefit Source of verification and date, if different from face-to-face contact Benefit amount Date received If representative contacted, name and telephone number
Private pensions (retirement benefits) Former employer Union Insurance company	Current check stub Pension plan Letter from company Contact with company representative	Name of payor/payee/beneficiary, if different from applicant's name Source of verification and date, if different from face-to-face contact Gross benefits amount Date received Claim number Whether any increase is anticipated If representative contacted, name and telephone number
Civil service annuity (CSA)	Recent CSA increase award card Letter from CSA Contact with CSA representative Current check Form 1243	Name of payee/beneficiary, if different from applicant's name Source of verification and date, if different from face-to-face contact Gross benefit amount before deductions for health insurance Date received Claim number If representative contacted, name and telephone number
Irrevocable trust funds	Trust agreement Will Trustee Representative of bank or financial institution managing trust Recent bank statement	Name of trustee/beneficiary, if different from applicant's name Source of verification and date, if different from face-to-face contact Amount and frequency of income from trust to individual Date of bank statement If trustee or representative contacted, name and telephone number
Veterans Administration (VA) benefits Pension Compensation (disability) Subsistence allowance for education and on-the-job training Refunds paid to ex-servicemen (GI insurance premiums)	Current check or direct deposit slip Recent bank statement Form 1240 Recent VA Award Letter Contact with VA representative	Name of recipient, if different from applicant's name Type of benefit Source of verification and date, if different from face-to-face contact Gross payment amount and exclusions: Aid-and-attendance benefits VA Homebound Elderly Benefits Payments for purchase of medications Date received Claim number If representative contacted, name and telephone number
Educational loans and grants	School Organizations Clubs Institutions Award letter Government loans	Beneficiary, if different from applicant's name Payor Type of loan or grant Amount received for current living costs Source of verification and date Date received and period covered (frequency) If representative contacted, name and telephone number
Unemployment compensation Government Private Strike benefits from union funds	Texas Workforce Commission Form B-11 or other official correspondence Recent check Recent bank statement Contact with government agency, employer, union	Payee/payor, if different from applicant's name Source of verification and date, if different from face-to-face contact Gross amount received Date received and period covered (frequency) Claim number If representative contacted, name and telephone number
Worker's compensation and disability payments	Recent check Attorney Claim Adjuster Recent bank statement Legal Correspondence Correspondence from insurance company Employer	Payee/beneficiary, if different from applicant's name Source of verification and date, if different from face-to-face contact Gross amount received Date received and frequency Length of disability Lump-sum settlement If collateral contacted, name and telephone number
Alimony	Contact ex-spouse Divorce Decree Court/payment records Recent check Receipts	Payor Source of verification and date, if different from face-to-face contact Amount received Date received and frequency If collateral contacted, pertinent name and telephone number
Cash support payments from friends or relatives (regular monthly)	Contact or statement from contributor Recent check Receipts	Payee/beneficiary, if different from applicant's name Relationship/name/address and telephone number of payor Source of verification and date, if different from face-to-face contact Amount received and frequency (exclude if infrequent or irregular and less than $20/mo.)
Net income from individual's share of life estate Mineral lease Bonus payments Delays rentals Shut-in royalty Other types of leases (farming, grazing, hunting) Rental	Lease agreements Rental agreements Oil company representative Check stubs Lessee or tenant (renter)	Payee, if different from applicant's name Payor Source of verification and date, if different from face-to-face contact Gross amount Date received and frequency If representative contacted, name and telephone number Address and telephone number of lessee or tenant
Teacher retirement (TRS)	Form 1297 Contact with TRS employee Recent check if previously verified no deductions	Payee/beneficiary, if different from applicant's name Source of verification and date, if different from face-to-face contact Gross benefit amount Claim number Date received If TRS representative contacted, name and telephone number