Texas Employment Verification Form H1028 – Fill Out and Use This PDF

Form H1028 is an Employment Verification Form used by the Texas Health and Human Services Commission (HHSC) to verify a person's employment and income when determining eligibility for various benefits programs.

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Texas Employment Verification Form PDF Details

The H1028 form is used to collect information from an individual's employer, such as their name, address, and employment dates, as well as their current salary or hourly wage. This form is typically used in the application process for programs such as Medicaid, Temporary Assistance for Needy Families (TANF), and Supplemental Nutrition Assistance Program (SNAP), among others. The purpose of the form is to ensure that individuals are receiving the appropriate level of benefits based on their income and employment status.

You can find information about the type of form you would like to submit in the table. It can tell you how long it will take to finish texas employment verification form, what parts you will have to fill in, etc.

Question	Answer
Form Name	Texas Employment Verification Form
Form Length	2 pages
Fillable?	Yes
Fillable fields	1
Avg. time to fill out	42 sec
Other names	verification of employment form texas, texas employment verification form printable, employee verification form, texas employment verification form pdf

12

Form Preview Example

Name and Address

Date

Need help? Call 2-1-1 or 877-541-7905.

Fax: 877-447-2839

Mail:

Texas Health and Human Services Commission

P O BOX 149027

Austin, Texas 78714-9027

If you are deaf, hard of hearing, or speech impaired, call 7-1-1 or 800-735-2989. All numbers are free to call.

Case Name

Case No.

This form is for your employer. They need to fill out the form and return it by. You must agree to let them give facts about you.

Fill Out and Sign This Agreement

I,		(print your name) allow HHSC to give my Social Security number (SSN) to the employer listed on this form.

My SSN can be used to get facts about my employment. I also allow the employer listed on this form to give facts asked on this form to HHSC.

Signature

Date

Employer – Your Help Is Needed

Employee or Former Employee

Social Security No.

We need proof that the following person is or was your employee.

Some employers might get tax refunds or tax credits for hiring people who get certain state benefits.

To learn more, go to TexasWorkforce.org/wotc or email the Texas Workforce Commission at wotc@twc.state.tx.us.

Employer please follow these steps.

This person lives in a home in which someone is applying for state benefits. We need to know the amount of money this person makes or made from this job.

1.Please fill out the “Proof of Employment” form on the next page.

2.If a question doesn't apply, mark it with "N/A."

3.Return the form:

To send this back to us, you can either:

(a)give it to the employee listed above,

(b)mail it in the pre-paid envelope, or (c) fax it to 877-447-2839.

Form H1028 / 07-2022

Employment Verification

Form H1028

Page 2 / 07-2022-E

Proof of employment to be filled out by the employer.

Company or Employer

Address (Street, City, State, ZIP code)

Employee Name (as shown on your records)

Employee Address (Street, City, State, ZIP Code – as shown on your records)

Is (or was) this person employed by you?		If yes, what type of job?
Yes	No	Full Time	Part Time	Permanent	Temporary

If no: Stop here – sign and date the bottom of this form and return it.

If yes: Answer all the questions below. If a question doesn’t apply, write “N/A".

Rate of Pay	Per Day	Per Week	Per Month	Per Job
Per Hour

How Often Paid?

Average Hours Per Pay Period

Commissions Tips Bonuses		Overtime Pay			FICA or FIT Withheld		Profit Sharing or Pension Plan
Yes	No	Frequently	Rarely	Never	Yes	No	Yes	No If yes, current value?

Health insurance available?		If yes, employee is:					Name of Insurance Company
Yes	No	Not Enrolled	Enrolled with Family Member		Enrolled for Self Only

Date Hired		Date First Check Received		Average Hours Per Week		If Employee	is or was on Leave Without Pay:
						Start Date:		End Date:

Do you expect any changes to the above information within the next few months? Yes No

If yes, explain:

On the chart below, list all wages received by this employee during the month(s) of:

Date Pay

Period Ended

Date Employee

Received Paycheck

Actual Hours

Gross

Pay

Other Pay*

(tips, commissions, bonuses)

EITC

Advance

Total Pretax

Contributions

*Please explain (in comments section below) when and how often tips, commissions, or bonuses are received. Comments

If this person is no longer in your employ.

	Date Separated	Reason for Separation					Date Final Check Received			Gross Amount of Final Check

	Employer – Read, Sign and Date

	I confirm that this information is true and correct to the best of my knowledge:

	Employer Signature			Date			Title		Area Code and Phone No.

How to Edit Texas Employment Verification Form Online for Free

With the objective of making it as effortless to use as possible, we designed our PDF editor. The process of preparing the employment verification form texas pdf is going to be very simple in the event you consider the next actions.

Step 1: Choose the orange button "Get Form Here" on the web page.

Step 2: At the moment, it is possible to change the employment verification form texas pdf. Our multifunctional toolbar helps you include, remove, adjust, highlight, as well as undertake other sorts of commands to the content material and fields inside the form.

The following sections will help make up the PDF form:

example of blanks in texas employment verification form

Jot down the data in Employer Your Help Is Needed, Employee or Former Employee, Social Security No, We need proof that the following, Some employers might get tax, To learn more go to, Employer please follow these steps, This person lives in a home in, Please fill out the Proof of, If a question doesnt apply mark, Return the form, and To send this back to us you can.

part 2 to finishing texas employment verification form

In the Company or Employer, Address Street City State ZIP code, Employee Name as shown on your, Employee Address Street City State, Is or was this person employed by, If yes what type of job, Yes, Full Time, Part Time, Permanent, Temporary, If no Stop here sign and date the, Rate of Pay, Per Hour, and Per Day field, emphasize the valuable particulars.

texas employment verification form Company or Employer, Address Street City State ZIP code, Employee Name as shown on your, Employee Address Street City State, Is or was this person employed by, If yes what type of job, Yes, Full Time, Part Time, Permanent, Temporary, If no Stop here sign and date the, Rate of Pay, Per Hour, and Per Day blanks to fill

The Date Pay Period Ended, Date Employee Received Paycheck, Actual Hours, Gross Pay, Other Pay tips commissions bonuses, EITC Advance, Total Pretax Contributions, Please explain in comments, Comments, If this person is no longer in, Date Separated, Reason for Separation, Date Final Check Received, Gross Amount of Final Check, and Employer Read Sign and Date area is the place to indicate the rights and obligations of all sides.

Entering details in texas employment verification form stage 4

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