Downloading a Form to Your Computer

Fillable forms cannot be viewed on mobile or tablet devices. Follow the steps below to download and view the form on a desktop PC or Mac.

  1. Right Click for PC or Ctrl + Click for Mac on the PDF link and click “Save link as” from the menu.
  2. Select the folder you want to save the file in and then click "Save."
  3. Navigate to the folder you saved the file in and Right Click for PC or Ctrl + Click for Mac, then select "Open With" from the menu and select Adobe Acrobat Reader DC.

Note: Open the PDF file from your desktop or Adobe Acrobat Reader DC. Do not click on the downloaded file at the bottom of the browser since it will not open the PDF in Adobe Acrobat Reader DC. It will try to open the file in the browser that results in the same browser error message.

If still having trouble viewing or downloading a form, click here.

Effective Date: 
9/2018

Documents

Instructions

Updated: 12/2010

 

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-FTI when a client cannot furnish sufficient verification of income or mandatory deductions. Staff send the form to the employer for completion of Pages 2 and 3.

Transmittal

Attach Form H0003, Authorization to Furnish Information, (signed by the applicant, recipient or responsible person) to the original.

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

Form Retention

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

Detailed Instructions

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.

Federal Tax Information — If the request is based on information obtained on an Automated System for the Office of Inspector General (ASOIG) Match Worksheet, check the Yes box. Do not include a copy of the ASOIG Match Worksheet with the request. If the request is not based on information obtained on an ASOIG Match Worksheet, check the No box.

HHSC staff

  • sign on Page 1,
  • enter the date and local office telephone number, and
  • enter the Return Form To: information on Page 2.

The employer completes all other items on Pages 2 and 3.