Texas Form H1028 PDF Details

Are you curious about Texas Form H1028 and what it means for your business? Whether you're a Texas resident looking to set up a new business or are already managing an existing company, understanding the specifics of Form H1028 is essential. This blog post will walk through everything you need to know in order to properly handle this document – from basic information on why it exists, to detailed instructions about filling out each section. With clear explanations and helpful tips, by the end of this article you'll have all the knowledge necessary to successfully complete Form H1028!

QuestionAnswer
Form NameTexas Form H1028
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesh1028 form, 1028 employment form texas benefits, form 1028 health, h1028

Form Preview Example

Employer Name and Address

Date

HHSC Staff

Office Address/Telephone No./FAX No.

EMPLOYMENT VERIFICATION (Aged and Disabled Programs)

Employee/Household Member

Social Security No.

This individual is a member of a household applying for assistance from the Texas Health and Human Services Commission or has income that affects another household member's application for assistance. To determine the household's eligibility, it is necessary to verify all earnings. Since this person is (or was) your employee, your help is needed.

HERE'S HOW YOU CAN HELP: Please provide the information requested in this letter. Please ensure that all information is complete and correct, since it will affect someone's eligibility and benefits. If a question does not apply, mark it N/A. After you complete the form, give it to your employee or mail it in the envelope provided – or you may FAX it to the number listed above.

This information is needed by

 

, so if you could send it before this date it would be most appreciated.

(Due Date)

Authorization to furnish this information is attached. Thank you for helping. If you have questions, please feel free to call.

TAX SENSITIVE INFORMATION (Check the appropriate box.)

Yes

No

THANK YOU for taking the time to complete all of the information on pages 2 and 3. Your help is greatly appreciated.

On the chart on page 3, list all wages received by this employee during the month(s) of:

Beginning Month (MM,DD,YYYY)

Ending (or current) Month (MM,DD,YYYY)

through

Telephone No. (inc. area code)

Signature–HHSC Staff

Date

EMPLOYER–PLEASE COMPLETE AND RETURN PAGES 2 & 3

Form H1028-A-TSI / 07-2005

Form H1028-A –TSI

Page 2 / 07-2005

EMPLOYMENT VERIFICATION

(Aged and Disabled Programs)

PLEASE COMPLETE AND RETURN PAGES 2 AND 3 ONLY

THANK YOU for taking the time to complete all of the information on pages 2 and 3. Your help is greatly appreciated.

Employee Name (as shown on your records)

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

Is (or was) this person employed by you?

 

If yes, what type of job?

 

 

 

 

Full

 

Part

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Permanent

Temporary

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

Time

 

Time

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Rate of Pay

 

 

 

Per

Per

 

Per

Per

 

 

Per

 

How often paid?

 

 

Avg. Hrs. per Pay Period

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hr.

Day

 

Week

Month

 

 

Job

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Commissions/Tips/Bonuses

Overtime Pay

 

 

 

 

FICA or FIT withheld

 

Profit Sharing/Pension Plan?–If yes, Current Value

Yes

No

 

Frequently

Rarely

Never

 

Yes

No

 

 

Yes

No $

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Health Insurance Available?

 

If yes, employee is:

 

Enrolled With

 

Enrolled for

Name of Insurance Company

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

 

Not Enrolled

 

Family Members

 

Self Only

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date Hired

 

 

Date First Check Rec’d

 

Average Hrs. Per Week

If Employee is/was on

 

Start Date

 

 

End Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Leave Without Pay:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Do you expect any changes to the above information within the next few months?

Yes

No

If yes, explain:

RETURN FORM TO:

Eligibility Specialist

Telephone No.

Fax No.

Address

Please remember to complete page 3

Form H1028-A-TSI

Page 3 / 07-2005

EMPLOYMENT VERIFICATION (Aged and Disabled Programs) — Continued

THANK YOU for taking the time to complete all of the information on this form. Your help is greatly appreciated.

On the chart below, list all wages received

Beginning Month (MM, DD, YYYY)

 

Ending (or Current) Month (MM, DD, YYYY)

 

 

 

 

 

by this employee during the month(s) of:

 

 

thru

 

DATE PAY

DATE EMPLOYEE

 

 

 

OTHER PAY*

NET AMOUNT OF

ACTUAL HOURS

GROSS PAY

 

(tips, commissions,

PERIOD ENDED

RECEIVED PAYCHECK

 

CHECK

 

 

 

bonuses)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

IF THIS PERSON IS NO LONGER IN YOUR EMPLOY:

Date Separated

Reason for Separation

Date Final Check Received

Gross Amount of Final Check

COMMENTS:

Company or Employer

Address (Street, City, State, ZIP)

This information is true and correct to the best of my knowledge and belief.

Title

Telephone No.

Signature–Person Verifying this Information

Date

How to Edit Texas Form H1028 Online for Free

Any time you intend to fill out form 1028 human, you won't have to download and install any sort of software - just use our online PDF editor. Our editor is consistently evolving to provide the very best user experience attainable, and that is because of our dedication to constant improvement and listening closely to comments from users. Getting underway is easy! All you should do is take the following simple steps directly below:

Step 1: Hit the "Get Form" button above on this page to open our PDF tool.

Step 2: This editor allows you to work with nearly all PDF files in a variety of ways. Modify it with any text, adjust what's already in the file, and include a signature - all at your fingertips!

This PDF form requires specific data to be typed in, so be sure to take your time to enter exactly what is required:

1. Start filling out your form 1028 human with a number of necessary fields. Gather all of the necessary information and ensure absolutely nothing is forgotten!

Simple tips to complete texas form 1028 step 1

2. Once your current task is complete, take the next step – fill out all of these fields - EmployeeHousehold Member This, This information is needed by, so if you could send it before, Due Date, TAX SENSITIVE INFORMATION Check, Yes No, THANK YOU for taking the time to, On the chart on page list all, Beginning Month MMDDYYYY, Ending or current Month MMDDYYYY, through, SignatureHHSC Staff, Telephone No inc area code, Date, and EMPLOYERPLEASE COMPLETE AND RETURN with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

texas form 1028 conclusion process shown (part 2)

3. Completing Employee Name as shown on your, Employee AddressStreet City State, Is or was this person employed by, If yes what type of job, Yes, Rate of Pay, Per Hr, Per Day, Full Time, Part Time, Permanent, Temporary, Per Week, Per Month, and Per Job is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

Completing part 3 in texas form 1028

It is possible to make errors when filling out your Employee AddressStreet City State, hence you'll want to look again prior to deciding to finalize the form.

4. The following subsection will require your information in the subsequent parts: Telephone No, Fax No, Please remember to complete page, Eligibility Specialist, and Address. Ensure that you provide all needed information to move further.

Fax No, Address, and Telephone No in texas form 1028

5. This pdf must be concluded by going through this segment. Here you will see a full listing of fields that must be completed with specific details to allow your form submission to be faultless: On the chart below list all wages, DATE PAY, DATE EMPLOYEE, PERIOD ENDED, RECEIVED PAYCHECK, cid, Beginning Month MM DD YYYY, thru, Ending or Current Month MM DD YYYY, ACTUAL HOURS, GROSS PAY, OTHER PAY, tips commissions, bonuses, and NET AMOUNT OF.

Completing part 5 in texas form 1028

Step 3: Proofread the details you have inserted in the blanks and then press the "Done" button. Download the form 1028 human the instant you register at FormsPal for a free trial. Quickly get access to the pdf document from your personal account, along with any modifications and changes automatically preserved! When using FormsPal, you're able to complete forms without stressing about personal information incidents or data entries getting shared. Our secure system makes sure that your private information is kept safely.