Form H1028 at a glance
What it is: Form H1028 Employment Verification is proof of employment to be filled out by the employer.
Where and when to file: Mail: Texas Health and Human Services Commission PO BOX 149027 Austin, Texas 78714-9027
This form is for your employer. They need to fill out the form and return it. You must agree to let them give facts about you.
A filled-in Form H1028 example: an employer verifies a job
How to fill out Form H1028, box by box
Fill Out and Sign This Agreement
Fill out and sign this agreement. Print your name to allow HHSC to give your Social Security number (SSN) to the employer listed on this form. Your SSN can be used to get facts about your employment. You also allow the employer listed on this form to give facts asked on this form to HHSC. Add your signature and the date.
Employee or Former Employee
Enter the Employee or Former Employee Social Security No.
Company or Employer and Employee
Enter the Company or Employer and Address (Street, City, State, ZIP code). Enter the Employee Name (as shown on your records) and Employee Address (Street, City, State, ZIP Code - as shown on your records).
Is (or was) this person employed by you?
Is (or was) this person employed by you? Yes or No. If no: Stop here - sign and date the bottom of this form and return it. If yes: Answer all the questions.
If yes, what type of job? Full Time, Part Time, Permanent or Temporary.
Rate of Pay
Enter the Rate of Pay and mark Per Hour, Per Day, Per Week, Per Month or Per Job. Enter How Often Paid? and Average Hours Per Pay Period.
Commissions, Tips, Bonuses, Overtime Pay, FICA or FIT Withheld and Profit Sharing
Mark Commissions, Tips, Bonuses, Overtime Pay and FICA or FIT Withheld.
Profit Sharing or Pension Plan: Yes or No. If yes, current value?
Health insurance available?
Health insurance available? If yes, employee is: Not Enrolled, Enrolled with Family Member or Enrolled for Self Only. If yes, enter the Name of Insurance Company.
Date Hired and Leave Without Pay
Enter Date Hired, Date First Check Received and Average Hours Per Week. If Employee is or was on Leave Without Pay: Start Date and End Date.
Do you expect any changes to the information within the next few months?
Do you expect any changes to the information within the next few months? Yes or No. If yes, explain.
Wages received by this employee
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 and Total Pretax Contributions.
Other Pay* (tips, commissions, bonuses): * Please explain (in comments section) when and how often tips, commissions, or bonuses are received. Comments
If this person is no longer in your employ
If this person is no longer in your employ: Date Separated, Reason for Separation, Date Final Check Received and Gross Amount of Final Check.
Employer - Read, Sign and Date
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.
More rules for Form H1028
Employer please follow these steps. 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."
If a question doesn't apply, write "N/A".
Need help? Call 2-1-1 or 877-541-7905.
Common questions about Form H1028
Where do I file it?
Return the form. You can either: (a) give it to the employee listed in Employee or Former Employee, (b) mail it in the pre-paid envelope, or (c) fax it to 877-447-2839.
Sources
[1] Texas Employment Verification Form H1028 (07-2022), Texas Health and Human Services Commission (the Official source link on this page).
