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Effective Date: 



Updated: 12/2010


To request information about an applicant's/recipient's mineral rights.


When to Prepare

If the applicant/recipient reports ownership of or income from mineral rights, the eligibility worker sends Form H1242-FTI to a knowledgeable source to verify the fair market value and income.

Number of Copies

The eligibility worker completes an original and one copy.


The eligibility worker sends the original to the knowledgeable source and retains the copy in the case record. After the original is returned to HHSC, the eligibility worker files the original in the case record and destroys the copy.

Form Retention

Keep the original copy according to the retention requirements of the case record.

Detailed Instructions

Inside Address — Enter the name and address of the verification source.

Enter date, name of the eligibility worker and office mailing address and telephone number.

Signature — Obtain the signature of the client or representative.

Date — Self-explanatory.

On Page 1, enter the client's name, address and Social Security number.

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.

The worker signs on Page 1, and enters the date and local office telephone number. The worker enters the Return Form To: information on Page 2. The company representative completes other the items on Page 2.