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Effective Date: 




Updated: 10/2002



To request information about clients' bank accounts.



When to Prepare

The case manager sends Form H1239 to a bank to get information about the bank accounts of a client.

Number of Copies

The case manager completes an original and makes a note on Form H0007-A, Activity Record, or prepares a copy for the case record. (Follow regional instructions).


The case manager sends the original to the financial institution.

Form Retention

If a copy is made for the case record, keep the copy according to the retention requirements of the case record.


Detailed Instructions

Inside Address — Enter the name and address of the financial institution.

Enter the date, name of the case manager, and the office mailing address and telephone number.

Enter the name of the client. Enter the account number(s), if known.

Enclose Form H0003, Authorization to Furnish Information, and a return envelope.