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Effective Date: 
7/2005

Documents

Instructions

Updated: 7/2005

Purpose

To provide HHSC staff with

  • an employer-completed verification of employment, wages, mandatory withholdings and deductions.
  • a source for documenting earned income and projecting changes in income when other methods are unavailable or insufficient.

Procedure

When to Prepare

Use Form H1028-A when a client cannot furnish sufficient verification of income or mandatory deductions. Staff send the form to the employer for completion.

Number of Copies

Send the employer Form H1028-A with an addressed, postage-paid envelope.

Transmittal

File the completed form in the appropriate section of the case record.

Detailed Instructions

On the first page of the form, enter the employer's name and address in the window space. Enter the date the form is prepared and the HHSC staff person's name, office address, telephone number and FAX number in the spaces provided.

Enter the employee's name and Social Security number in the appropriate spaces and all other required information at the bottom of page one of the form.

On page two of the form above the chart, enter the month(s) that wage information is needed.

The employer completes the rest of the form. All items are self-explanatory.