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Effective Date: 





Updated: 10/2002


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

Signature — Obtain the signature of the client or his representative.

Date — Self-explanatory.

Enter the client's name, address, Social Security number, and any available property information.