- 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.
When to Prepare
Use manual Form H1028 when TIERS is down and a person cannot furnish sufficient verification of income or mandatory deductions. Send the form to the person to take it to the employer for completion. Document in the household’s case record the date the form is given to the person.
Number of Copies
Give or send the person or employer one copy of Form H1028 with an addressed return envelope.
Save the completed form with the case record.
HHSC staff enter the following information before sending.
Date — Enter the date the form is sent to the household in the top right corner of the form.
Name and address — Enter the name and address of applicant, recipient or authorized representative.
Case Name — Enter the name of the person exactly as it is spelled in the Texas Integrated Eligibility Redesign System (TIERS).
Case No. — Enter the TIERS case number of the person.
They need to fill out the form… — Enter the next available work date that is 10 days from the date the form is sent to the client.
Employee or former employee — Enter the name of the person.
Social Security Number — Enter the Social Security Number of the person.
The applicant, recipient or authorized representative must authorize the release of their SSN on page 1.
Requestor’s Signature — The person authorizing release of the verification of employment prints their name and signs and dates the form.
The proof of employment on page 2 is completed by the employer:
Company or Employer — Enter the name of the person’s company or employer.
Address — Enter the address of the person’s company or employer.
Employee Name — Enter the name of the person.
Employee Address — Enter the address of the person.
Is (or was) this person employed by you? — Check the box if the person is currently employed or was formerly employed by the employer completing the form.
If yes, what type of job? — Enter the job title and check one or more boxes to indicate if the person has been employed Full Time, Part Time, Permanent or Temporary.
Rate of Pay — Enter the person’s pay amount and check the box that indicates the rate of pay.
How Often Paid? — Check one or more boxes to indicate how often the person has been paid.
Average Hrs. per Pay Period — Enter the average number hours the person has worked per pay period.
Commission, Tips or Bonuses — Check the box to indicate if the person has received any commissions, tips or recent bonuses.
Overtime Pay — Check the box to indicate how often the person has received overtime pay.
FICA or FIT withheld — Check the box to indicate if the person has had Federal Insurance Contributions (FICA) or Federal Income Tax (FIT) withheld.
Profit Sharing/Pension Plan — Check the box to indicate if the person has a profit sharing or pension plan.
If yes, current value — Enter the current value of the person’s profit sharing or pension plan.
Health insurance available? — Check the box to indicate if the employer completing the form offers health insurance.
If yes, employee is — Check the box to indicate the enrollment status of the person.
Name of insurance Company — Enter the name of the insurance company the person is enrolled in.
Date hired — Enter the hire date of the person.
Date first check received — Enter the date of person’s first check.
Average hours per week — Enter the average hours the person has worked per week.
If employee is or was on Leave Without Pay — Enter the start date and end date the person has been on leave without pay.
Do you expect any changes to the above information within the next few months — Check the box to indicate if the employer completing the form expects any changes to the facts above within the next few months.
If yes, explain — Enter what facts will change within the next few months.
On the chart below, list all wages received by this employee during the months(s) of: — Enter the month that is associated to the information in the chart.
Date Pay Period Ended — Enter the dates the pay periods ended.
Date Employee Received Paycheck — Enter the dates the person has received paychecks.
Actual Hours — Enter the person’s actual hours worked.
Gross Pay — Enter the person’s gross pay amounts.
Other Pay — Enter the person’s other pay amounts.
EITC Advance — Enter the person’s Earned Income Tax Credit (EITC) amounts.
Total Pretax Contributions — Enter the person’s pretax contributions.
Comments — Enter other comments that explain when and how often the person has received tips, commissions or bonuses.
If this person is no longer in your employ.
Date Separated — Enter the date the person separated from employment.
Reason for Separation — Enter the reason the person separated from employment.
Date final Check Received — Enter the date the person received their last check.
Gross Amount of Final Check — Enter the gross amount of the last check the person received.
Signature of Employer — Employer's signature who is completing the form.
Date of Signature — Date of employer's signature.
Title — Employer's title.
Area Code and Phone Number — Employer's area code and phone number.