Form H1020-A, Sources of Proof

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Effective Date: 6/2007



Updated: 4/1989



To provide TANF, food stamp, and Medicaid clients with a list of acceptable sources of verification required to determine eligibility.


When to Prepare

Provide Form H1020-A to the household if the household's case is held pending receipt of verification.

Attach to Form H1020 the page(s) of Form H1020-A that corresponds to the verification requested. GWS staff attach the appropriate page(s) of Form H1020-A to the computer-printed Form H1020.

Number of Copies/Transmittal

Give one copy to the applicant.

Form Retention

There is no retention requirement for this form.

Detailed Instructions

Check the box that corresponds to the eligibility criteria for which proof is pending as noted on Form H1020.

Advise the client that if he cannot obtain the type of proof requested on Form H1020, that other potential sources of proof are listed on Form H1020-A.