Form H1155 at a glance
What it is: Form H1155 (11-2025) is the Request for Domicile Verification. It is completed by a non-relative who does not live with the client.
Where and when to file: Complete page 2. Return it in the envelope provided or fax to HHSC at 887-447-2839 by the date.
A non-relative who does not live with the client must complete this form.
A filled-in Form H1155 example: a neighbor verifies a household
How to fill out Form H1155, box by box
Complete page 2 and return it
Complete page 2. Return it in the envelope provided or fax to HHSC at 887-447-2839 by the date.
Name, Relationship to Client and Name of Employer
List all the people living in the home, including the client named on the front of this form. Enter the Name, Relationship to Client and Name of Employer for each, with the client on the Client: row.
I can verify the information because I am
Mark why you can verify the information: A Neighbor, An Employer, A School Official, A Clergy person, A Friend, A Landlord, A Child Care Provider, or Other, explain:.
How long have you known the family
Enter how long you have known the family in Years, Months and Weeks.
Printed Name, Signature and Date
Enter your Printed Name, sign under Signature and enter the Date.
Street Address, City, State and ZIP Code and Area Code and Phone No.
Enter your Street Address, City, State and ZIP Code and your Area Code and Phone No.
Common questions about Form H1155
What is a request for domicile verification?
Form H1155 (11-2025) is the Request for Domicile Verification. It is completed by a non-relative who does not live with the client. You are listed as not related to the client but familiar with their family, and your help is needed to correctly evaluate the household's situation.
Sources
[1] Form H1155 (11-2025), Request for Domicile Verification, Texas Health and Human Services Commission (the Official source link on this page).