Form H1135, Child Care Expense Verification

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Effective Date
H1135.pdf (86.02 KB)
H1135-S.pdf (1.71 MB)



Updated: 5/2003



To provide staff with a form to request child care expense verification from a child care provider.


When to Prepare

Use this form to request verification of child care expenses if the client does not have another source of verification.

Number of Copies

Give or mail the client or the child care provider one copy of the form with an addressed, stamped envelope.


File the completed form on the right side of the case folder with the appropriate application or change form.


See the Texas Works Manager's Guide.


Staff enters the

  • name and address of the person or company providing the care;
  • date, advisor's name, office address, and telephone/fax number;
  • case name and case number;
  • date the information is due; and
  • client's name in the space giving his permission for release of the requested information. The client signs and dates the form in the appropriate spaces.

The child care provider completes the remainder of the form.