Complete the information requested on page 2 of this letter.
People: list all the people living in the home, including the client named on the front of this form, with name, relationship to client and name of employer.
Who can verify: a neighbor, an employer, a school official, a clergy person, a friend, a landlord, a child care provider or other.
Return: in the postage paid envelope provided, as soon as possible, but no later than the date in this letter.
| Question | Answer |
|---|---|
| Form Name | Form H1155 |
| Form Length | 2 pages |
| Fillable? | Yes |
| Fillable fields | 74 |
| Avg. time to fill out | 13 min |
| Edition | 11-2025 |
| Who completes it | A non-relative who does not live with the client |
| Where to send | In the postage paid envelope provided |
| Other names | H1155, Form H1155, H1155 form, Domicile Verification, Request for Domicile Verification |
| Official source | Form H1155 (11-2025), HHSC |
Form H1155 isn’t the one you’re looking for?